SECOND SEMI-ANNUAL REPORT OF THE
INDEPENDENT MONITOR OF THE MEMORANDUM
OF AGREEMENT BETWEEN THE UNITED STATES
DEPARTMENT OF JUSTICE AND THE STATE OF
DELAWARE REGARDING THE DELORES J. BAYLOR
WOMEN’S CORRECTIONAL INSTITUTION, THE
DELAWARE CORRECTIONAL CENTER, THE
HOWARD R. YOUNG CORRECTIONAL INSTITUTION
AND THE SUSSEX CORRECTIONAL INSTITUTION

JOSHUA W. MARTIN III
INDEPENDENT MONITOR
1313 N. Market Street
P. O. Box 951
Wilmington, DE 19899-0951
302-984-6000
deprisonmonitor@potteranderson.com
www.deprisonmonitor.org

Dated: January 31, 2008

INDEPENDENT MONITORING TEAM
INDEPENDENT MONITOR
Joshua W. Martin III
Potter Anderson & Corroon LLP
1313 North Market Street
P.O. Box 951
Wilmington, DE 19899-0951
Phone: 302-984-6010
Fax: 302-658-1192
deprisonmonitor@potteranderson.com
POTTER ANDERSON MONITORING TEAM
Suzanne M. Hill, Esq.
Michael B. Rush, Esq.
MEDICAL AND MENTAL HEALTH CARE EXPERTS
Ronald Shansky, M.D., S.C.
Internist, consultant in correctional medicine
Michael Puisis, M.D.
Internist, consultant in correctional medicine1
Madeleine LaMarre, MN, APRN, BC
Nurse Practitioner, correctional health care consultant
Jeffrey L. Metzner, M.D.
Psychiatry, consultant in correctional medicine
Roberta E. Stellman, M.D., DABPN, CCHP, DFAPA
Psychiatry, consultant in correctional medicine

1

Dr. Puisis participated in monitoring during the period of time covered by this report. Dr.
Puisis resigned from the Monitoring Team effective December 31, 2007, however, and the
parties are in the process of selecting a replacement.

EXECUTIVE SUMMARY
This is the second report submitted pursuant to the MOA2 and the Monitoring
Agreement,3 covering the period from July 30, 2007 through December 31, 2007. During this
monitoring period, the Monitoring Team4 has visited each of the Facilities5 on multiple occasions
in order to provide technical assistance and conduct monitoring. In addition to the technical
assistance provided with regard to the provision of medical and mental health care during the
visits to the Facilities, the Monitoring Team was able to provide technical assistance with regard
to the drafting of the State’s new policies, and provide suggestions to the parties regarding the
appropriate definitions of substantial compliance for each provision of the MOA.
During this monitoring period, the Monitoring Team conducted interviews of leadership
and staff of Delaware Department of Correction (“DOC”) and Correctional Medical Services
(“CMS”),6 and inmates housed in the Facilities.7 In addition, the Monitoring Team has reviewed
between 100 to 200 medical records at each facility, except at Baylor, where approximately 50 to
100 files were reviewed due to the smaller size of this facility. All of these materials, in

2

The “MOA” refers to the Memorandum of Agreement between the United States Department
of Justice (“DOJ”) and the State of Delaware (the “State”) regarding the Delores J. Baylor
Women’s Correctional Institution, the Delaware Correctional Center, the Howard R. Young
Correctional Institution, and the Sussex Correctional Institution, which was entered into on
December 29, 2006. The MOA is attached to this report as Appendix I, and is available at
http://www.deprisonmonitor.org/pdf/delaware_prisons_moa_12-29-06.pdf.
3

The “Monitor Agreement” refers to the Agreement between Joshua W. Martin III (the
“Monitor”) Individually and on Behalf of Potter Anderson & Corroon LLP and the State of
Delaware, which was entered into on May 14, 2007 (the “Monitor Agreement”).
4

The Monitor has retained a team of medical and mental health experts. The Monitor, together
with the medical and mental health experts and other attorneys, are hereinafter referred to as the
“Monitoring Team.”

5

The term “Facilities” refers to the Delores J. Baylor Women’s Correctional Institution
(“Baylor”), the Delaware Correctional Center (“DCC”), the Howard R. Young Correctional
Institution (“HRYCI”), and the Sussex Correctional Institution (“SCI”).
6

CMS is a private contractor that has been providing medical and mental health care services at
the Facilities since it took over the prior vendor’s contract on July 1, 2005. The CMS website is
available at http://www.cmsstl.com.
7

The Monitoring Team also has received unsolicited information from inmates, their families,
advocates, community groups and other external sources, which has been taken into
consideration.

connection with the observations that the Monitoring Team made while on site at the Facilities,
form the basis of the compliance assessments8 contained in this Report.
The compliance assessments made in this report regarding the State’s compliance with
the provisions of the MOA are made by consensus of the Monitoring Team, which means that
the Monitoring Team reviews the evidence and determines whether the evidence shows
substantial, partial or no compliance with a provision of the MOA. The State and the DOJ
continue to discuss the approach to be used in the future with regard to measuring the State’s
compliance with the provisions of the MOA. Specifically, the parties are attempting to identify
with greater precision the relevant universe of documents to be reviewed, and, to the extent
feasible, objective indicators of compliance. The Monitor is hopeful that that approach will be in
place for the next report, which is due on or about June 29, 2008.
Summary of Findings
In the first report, the Monitor focused on describing problems with clinic space and
equipment available at each of the Facilities, the staffing of leadership positions, and
documenting and maintaining appropriate data so that both the Monitoring Team and the State
can measure the State’s performance. After the first report, the DOC created a Corrective Action
Plan to ameliorate the sanitation issues highlighted in the first report. The Monitoring Team
notes that the DOC has been more successful in maintaining sanitary infirmaries. Additionally,
the DOC has been fairly responsive to the Monitoring Team’s suggestions regarding the use of
certain spaces within the Facilities to ameliorate the budgetary and structural constraints of those
Facilities, resulting in some improvement in that regard. Clinic space and equipment, especially
as it relates to how lack of privacy can limit the adequacy of medical and mental health services
provided to inmates, is an issue that has arisen since the first report.
The lack of stable and effective leadership at the vendor-level remains a concern.
Without stable and effective leadership, the State will be significantly hampered in its attempts to
become compliant with the MOA. As will be seen throughout this report, while CMS has had
some success in filling leadership positions, there has continued to be turnover, and those
individuals filling the leadership positions have not yet had enough time in those positions for
their influence to be seen in results of this report. Moreover, there has been consistent turnover
at staff-level positions, and, at HRYCI in particular, there is a problem with staff insubordination
that needs to be addressed because it affects inmate medical and mental health services
negatively.
The Monitoring Team has also faced difficulty in receiving consistent and accurate
information from CMS. On a number of occasions, well-meaning individuals have given the
Monitoring Team information about a practice or procedure that they believe is being followed.
Upon further investigation by the Monitoring Team, it often turns out that such practice or
8

For those provisions of the MOA for which the Monitoring Team made an assessment, there
are three different compliance assessments possible: substantial compliance, partial compliance,
and non-compliance. These compliance assessments will be explained at greater length in the
introduction to the report.
2

procedure is not, in fact, being followed in spite of the belief of the individual providing
information. This is symptomatic of a lack of supervision of staff, and poor or non-existent selfmonitoring. The Monitoring Team recommends that CMS begin to self-monitor for compliance
with DOC policies as soon as possible so as to be able to assess its own compliance, and provide
the Monitoring Team with reliable information.
Additionally, the Monitoring Team has noted that in many medical records that have
been reviewed, both nursing and physician documentation of care is poor. Poor documentation
can be symptomatic of an overburdened staff without the time to keep up with filing,9 or of care
not being provided at all. In some cases, staff could be providing adequate care for an inmate but
is too busy to document that care. In that case, the Monitoring Team will be unable to make the
determination that there is adequate care because it is not properly documented in the inmate’s
medical record. On the other hand, the fact that there is inadequate documentation of the care
provided to an inmate can also indicate that, in fact, inadequate care is being provided to an
inmate. The Monitoring Team has found examples of both of these scenarios. In either case, the
lack of documentation creates difficulty in providing adequate medical care in future
circumstances because it will be more time consuming for staff to determine the inmates history.
Summary of State’s Compliance
The MOA contains fifty-five provisions which apply to Baylor, and fifty-four provisions
which apply to each of the other three facilities. The Monitoring Team’s assessments of the
Facilities are as follows:10
z

The Monitoring Team found Baylor in substantial compliance with nine of the
fifty-five provisions; in partial compliance with twenty-four of the provisions; and
in non-compliance with five provisions. The Monitoring Team did not assess
Baylor with respect to seventeen of the provisions.11

9

Medical records filing and maintenance is better left to individuals who are trained in that
specialty. The Monitoring Team has recommended that CMS hire appropriately qualified
individuals to supervise medical record-keeping on a statewide and facility level to ensure more
adequate medical record-keeping as well as alleviate an unnecessary burden on nursing staff.
CMS advertised for a central office position, but the Monitoring Team has not received
information regarding CMS’ continued efforts and success regarding recruiting for that position.
10

Certain provisions of the MOA contain separate assessments for medical and mental health
services. Thus, there are a greater number of specific assessments in the text of this report than
are discussed in the above summary. In order to count each provision of the MOA only once for
the purpose of the above summary, the Monitoring Team combined the medical and mental
health assessments.

11

Certain provisions were not assessed at each of the facilities for one of two general reasons.
First, some provisions were not monitored because of time constraints which prevented the
Monitoring Team from assessing all of the provisions. Second, certain provisions were not
assessed because the Monitoring Team deferred assessment at this time.
3

z

The Monitoring Team found that DCC was in substantial compliance with seven
of the fifty-four provisions; in partial compliance with thirty-four of the
provisions; and in non-compliance with two provisions. The Monitoring Team
did not assess DCC with respect to eleven of the provisions.

z

The Monitoring Team found that HRYCI was in substantial compliance with six
of the fifty-four provisions; in partial compliance with thirty-four of the
provisions; and in non-compliance with five provisions. The Monitoring Team
did not assess HRYCI with respect to nine of the provisions.

z

The Monitoring Team found that SCI was in substantial compliance with nine of
the fifty-four provisions; in partial compliance with twenty-six of the provisions;
and in non-compliance with five provisions. The Monitoring Team did not assess
SCI with respect to fourteen of the provisions.

While the State needs to continue improving, the Monitoring Team notes that during the
time period between the first report and this report, the State has completed a number of tasks
which are relevant to its obligations under the MOA, including the following:
z

Released the first of its semi-annual Compliance Reports on July 30, 2007;12

z

Drafted new and/or revised policies after consulting with the Monitoring Team,
and submitted those policies to the DOJ;

z

Received approval of all new and/or revised policies submitted to DOJ to date;13

z

Posted the DOC policies, Compliance Report, and Action Plan on the DOC
website;14

z

Implemented an updated version of the Delaware Automated Correctional System
(“DACS”) computer program and trained DOC and CMS personnel on that
program;

z

Recruited and hired a Compliance Coordinator, who performs a number of
important tasks to assist the State in achieving compliance with the MOA;

12

The State is required to report its progress toward implementing its Action Plan, which was
issued on April 5, 2007. See MOA ¶¶ 65, 66. The State’s next semi-annual Compliance Report
is scheduled to be issued on January 31, 3008. The first Compliance Report can be found at:
http://www.doc.delaware.gov/information/Prison%20health%20Care.shtml.

13

The DOC medical unit policies can be found at:
http://www.doc.delaware.gov/information/DOC_Policy_Manual6.shtml.
14

The Action Plan is attached as Appendix II to this report, and is available at:
http://doc.delaware.gov/information/Prison%20Health%20Care.shtml.
4

z

Trained 2,247 DOC staff on suicide prevention issues, as required under ¶ 43 of
the MOA;

z

Contracted with CMS for increased staffing at the Facilities based on
recommendations previously obtained from members of the Monitoring Team;

z

Conducted a campaign encouraging DOC inmates and personnel to be vaccinated
against the influenza virus, in accordance with recommendations issued by the
Centers for Disease Control (“CDC”); and

z

Has received approval for some plans to ameliorate the privacy and clinic space
concerns highlighted in the report.

5

TABLE OF CONTENTS
Page
INTRODUCTION ...........................................................................................................................1
Definition of Assessment Ratings........................................................................................1
Overview of Second Report.................................................................................................2
MEDICAL AND MENTAL HEALTH CARE ...............................................................................4
1.

Standard ...................................................................................................................4

2.

Policies and Procedures ...........................................................................................5

3.

Record Keeping .......................................................................................................6

4.

Medication and Laboratory Orders........................................................................13

STAFFING AND TRAINING ......................................................................................................16
5.

Job Descriptions and Licensure .............................................................................16

6.

Staffing...................................................................................................................18

7.

Medical and Mental Health Staff Management .....................................................22

8.

Medical and Mental Health Staff Training ............................................................26

9.

Security Staff Training...........................................................................................27

SCREENING AND TREATMENT ..............................................................................................31
10.

Medical Screening .................................................................................................31

11.

Privacy ...................................................................................................................35

12.

Health Assessments ...............................................................................................38

13.

Referrals for Specialty Care...................................................................................42

14.

Treatment or Accommodation Plans .....................................................................45

15.

Drug and Alcohol Withdrawal...............................................................................48

16.

Pregnant Inmates....................................................................................................50

i

17.

Communicable and Infectious Disease Management ............................................51

18.

Clinic Space and Equipment..................................................................................54

ACCESS TO CARE ......................................................................................................................59
19.

Access to Medical and Mental Health Services.....................................................59

20.

Isolation Rounds ....................................................................................................63

21.

Grievances..............................................................................................................66

CHRONIC DISEASE CARE ........................................................................................................68
22.

Chronic Disease Management Program.................................................................68

23.

Immunizations........................................................................................................70

MEDICATION ..............................................................................................................................73
24.

Medication Administration ....................................................................................73

25.

Continuity of Medication.......................................................................................77

26.

Medication Management .......................................................................................79

EMERGENCY CARE ...................................................................................................................83
27.

Access to Emergency Care ....................................................................................83

28.

First Responder Assistance ....................................................................................85

MENTAL HEALTH CARE ..........................................................................................................86
29.

Treatment ...............................................................................................................86

30.

Psychiatric Staffing................................................................................................88

31.

Administration of Mental Health Medications ......................................................90

32.

Mental Illness Training ..........................................................................................93

33.

Mental Health Screening........................................................................................94

34.

Mental Health Assessment and Referral................................................................96

ii

35.

Mental Health Treatment Plans .............................................................................99

36.

Crisis Services......................................................................................................101

37.

Treatment for Seriously Mentally Ill Inmates......................................................103

38.

Review of Disciplinary Charges for
Mental Illness Symptoms.....................................................................................105

39.

Procedures for Mentally Ill Inmates in
Isolation or Observation Status............................................................................107

40.

Mental Health Services Logs and Documentation...............................................110

SUICIDE PREVENTION............................................................................................................113
41.

Suicide Prevention Policy ....................................................................................113

42.

Suicide Prevention Training Curriculum .............................................................113

43.

Staff Training .......................................................................................................114

44.

Intake/Screening Assessment...............................................................................115

45.

Mental Health Records ........................................................................................116

46.

Identification of Inmates at Risk of Suicide ........................................................118

47.

Suicide Risk Assessment .....................................................................................120

48.

Communication....................................................................................................122

49.

Housing ................................................................................................................124

50.

Observation ..........................................................................................................126

51.

“Step-Down Observation” ...................................................................................127

52.

Intervention ..........................................................................................................129

53.

Mortality and Morbidity Review .........................................................................130

QUALITY ASSURANCE ...........................................................................................................132
54.

Policies and Procedures .......................................................................................132

iii

55.

Corrective Action Plans .......................................................................................133

CONCLUSION............................................................................................................................135

iv

INTRODUCTION
The First Semi-annual Report of the Independent Monitor for the State of Delaware
Department of Correction was published on June 29, 2007, and represented a preliminary
overview of the Monitor’s duties, and summaries of the Monitor’s first observations regarding
the State’s compliance with the MOA.15
This second report represents the Monitoring Team’s first opportunity to conduct and
report on monitoring of the facilities. The organization of the report is a review of each MOA
provision, any findings made by the Monitoring Team regarding that MOA provision, an
assessment of the State’s compliance with that provision of the MOA, and recommendations, if
any, to assist the State in reaching substantial compliance with a given provision of the MOA.
Between the publication of the first report and this second report, the Monitoring Team
visited the Facilities on a number of occasions to offer technical assistance and perform
monitoring, spending a great deal more time at the Facilities during October and November
2007. Also, during this time period, the State completed its new policies, and submitted those
policies to the DOJ for approval. The DOJ approved the policies. The State continues to
develop and revise the policies as needed. Further, the State is now in the process of developing
and implementing procedures at the facility level.
Additionally, the DOC and the DOJ continue to work cooperatively to identify with
greater precision the relevant universe of documents to be reviewed, and, to the extent feasible,
objective indicators of compliance. The Monitor is hopeful that that approach will be in place
for the next Report, which is due on or about June 29, 2008. For purposes of this report, the
Monitoring Team used a consensus approach to determine the State’s level of compliance with a
given MOA provision. This approach might change in future reports depending upon the
parties’ agreement regarding the proper substantial compliance metrics.
Definition of Assessment Ratings
Pursuant to paragraphs 71 and 72 of the MOA, the Monitor is required to review and
report on the State’s implementation of, and assist with the State’s compliance with, the MOA.
The Monitor must determine whether the State has successfully complied with each requirement
contained in the MOA at each of the Facilities. In order to make that determination, the parties
must agree upon appropriate measurements and standards against which the State’s performance
will be compared. The parties are discussing what will constitute substantial compliance for
each requirement of the MOA. The following are the assessment ratings used by the Monitoring
Team:

15

The first report can be found on the Monitor’s website, at the following address:
www.deprisonmonitor.org. The website contains an overview of the Monitor’s role, and links to
press releases and reports. All future reports will be posted on the website.

• The term “substantial compliance” shall mean that the State has satisfied the
requirements of all components of the assessed MOA provision. If the State has sustained
substantial compliance with all provisions of the MOA for a period of one year, then the State
may submit a written request to the DOJ for early termination of the MOA. See MOA ¶ 60. The
DOJ will determine whether the State has, in fact, maintained substantial compliance for the one
year period. Id. Otherwise, the MOA is designed to terminate after three years from December
29, 2006. See MOA ¶¶ 59 and 60. Non-compliance with mere technicalities, or temporary
failure to comply during a period of otherwise sustained compliance will not constitute failure to
maintain substantial compliance. See MOA ¶ 60. At the same time, temporary compliance
during a period of sustained non-compliance shall not constitute substantial compliance. Id.
• The term “partial compliance” shall mean that the State has achieved less than substantial
compliance with all of the components of a rated provision of the MOA, but has made some
progress toward substantial compliance on most of the key components of the rated provision. A
partial compliance rating encompasses a wide range of performance by the State. Specifically, a
partial compliance rating can signify that that the State is nearly in substantial compliance, or it
can mean that the State is only slightly above a non-compliance rating.
• The term “non-compliance” shall mean that the State has made negligible or no progress
toward compliance with all of the components of the MOA provisions being assessed.
Also, the Monitoring Team deferred assessing some provisions of the MOA while the
finalized policies were pending because the Monitoring Team believed that it would be
appropriate to allow for the implementation of required policies prior to conducting formal
monitoring, and to use the State’s compliance with its policies as the basis for the assessment of
the State’s compliance with the MOA. The State and the DOJ have informed the Monitoring
Team that this approach was not what the parties had contemplated, and that the Monitoring
Team should assess the State’s compliance against the generally accepted professional standards
that formed the basis of many of the State’s policies and procedures. The assessments that the
Monitoring Team made in this report are based upon those generally accepted professional
standards. For the purposes of future reports, whether a policy or procedure is pending or not
will not have any bearing on whether the Monitoring Team monitors and assesses a given
provision. In addition, the Monitoring Team deferred assessing some provisions of the MOA
because of time constraints. Finally, in some cases, the Monitoring Team was unable to assess
the State’s compliance with a provision because there were no relevant cases to review.
For the purposes of this second report, the Monitoring Team has reviewed the
information available to it, and assessed the level of the State’s compliance with each MOA
provision at each of the Facilities based upon a consensus approach. This means that for each
provision, the Monitoring Team reviews the evidence and determines whether the evidence
shows substantial, partial or no compliance with a provision of the MOA.
Overview of second report
This report acts as a baseline against which the State’s future improvement will be
compared. The State still has a great deal more to accomplish to come into substantial

2

compliance with the MOA, but now the State has information to use to assist with coming into
substantial compliance with the MOA.
The second report generally follows the format of the MOA. The MOA is organized into
three distinct substantive areas: (1) Medical and Mental Health; (2) Suicide Prevention; and (3)
Quality Assurance.16 The second report mirrors that format and contains individual sections
devoted to each of these three areas. Each MOA substantive provision is listed by MOA
paragraph number and is followed by some or all of the following:
z

a summary of the particular MOA requirements;

z

discussion, as appropriate, of any applicable generally accepted professional
standards which relate to the MOA provision;17

z

key findings made by the Monitoring Team;

z

an assessment of the State’s compliance with the relevant provision;

z

recommendations, if any, to assist the State in achieving substantial compliance
with the provision.18

16

See MOA ¶ 65 (defining Sections III through V as the “Substantive Provisions” of the MOA).

17

In this report, the monitor has cited to both NCCHC standards (or other appropriate standards).

18

Recommendations included in this Report are in the nature of technical assistance and do not
represent an obligation of the DOC pursuant to the MOA.
3

MEDICAL AND MENTAL HEALTH CARE
1.

Standard
A.

Relevant MOA Provision

Paragraph 1 of the MOA provides: “The State shall ensure that services to
address the serious medical and mental health needs of all inmates meet generally accepted
professional standards.”19 This provision of the MOA requires that the State provide services in
all of the areas set forth in the MOA according to generally accepted professional standards,
including but not limited to, the standards promulgated by the National Commission on
Correctional Health Care (“NCCHC”) for prisons and for jails. The Facilities are all used both
as jails20 and as prisons.21 For the most part, the NCCHC standards for jails and prisons are the
same; however, there are some notable differences based upon the different functions served by a
jail versus a prison, especially with regard to intake procedures. See e.g., discussion of provision

19

According to section II.C. of the MOA, “generally accepted professional standards” means:
[T]hose industry standards accepted by a significant majority of professionals in
the relevant field, and reflected in the standards of care such as those published by
the National Commission on Correctional Health Care (NCCHC). DOJ
acknowledges that NCCHC has established different standards for jail and prison
populations, and that the relevant standard that applies under this Agreement may
differ for pretrial and sentenced inmates. As used in [the MOA], the terms
“adequate,” “appropriate,” and “sufficient” refer to standards established by
clinical guidelines in the relevant field. The Parties shall consider clinical
guidelines promulgated by professional organizations in assessing whether
generally accepted professional standards have been met.

20

A “jail” is, “a detention facility where accused persons are detained until their alleged crime is
adjudicated before a jury or judge.” Joseph E. Paris, Ph.D., M.D., CCHP, FSCP, Interaction
Between Correctional Staff and Health Care Providers in the Delivery of Medical Care, in
Clinical Practice in Correctional Medicine (Michael Puisis, D.O. ed., 2006). Thus, “[f]or the
most part, persons in jails are not yet convicted of a crime, although some jails also house those
serving misdemeanor terms (1 year or less) as well as those serving county jail time as condition
of felony probation.” Id.
21

A “prison” is a “facilit[y] where persons are incarcerated as punishment for crimes for which
they have been convicted.” Joseph E. Paris, Ph.D., M.D., CCHP, FSCP, Interaction Between
Correctional Staff and Health Care Providers in the Delivery of Medical Care, in Clinical
Practice in Correctional Medicine (Michael Puisis, D.O. ed., 2006).

4

10 of the MOA, infra. As the DOJ has acknowledged in the MOA, the NCCHC has adopted
separate standards for prisons and for jails.22
B.

Assessment

As will be discussed at length below, the State has a great deal more to
accomplish to bring each of the Facilities into substantial compliance with all provisions of the
MOA. Overall, the Monitor found that the State is in partial compliance with this provision of
the MOA because the State has made some progress toward reaching substantial compliance
with it.
2.

Policies and Procedures
A.

Relevant MOA Provision

Paragraph 2 of the MOA provides:
The State shall develop and revise its policies and procedures including
those involving intake, communicable disease screening, sick call, chronic
disease management, acute care, infection control, infirmary care, and
dental care to ensure that staff provide adequate ongoing care to inmates
determined to need such care. Medical and mental health policies and
procedures shall be readily available to relevant staff.
This provision of the MOA requires that the State have policies23 and
procedures in place to address vital procedural steps in providing appropriate medical and
mental health care for inmates, and is meant to ensure that these policies and procedures are
readily available to relevant staff. According to NCCHC standards, policies and procedures
should be facility-specific. J-A-05; P-A-05.
24

B.

Findings

The State submitted its draft policies to the DOJ on July 5, 2007. As provided in
paragraph 61 of the MOA, any policies to which the DOJ did not object in writing were deemed
22

Unless otherwise noted, all references in the format of “J-__-__” shall refer to standards from
the Standards for Health Services in Jails, National Commission on Correctional Health Care
(2003). Likewise, unless otherwise noted, all references in the format o “P-__-__” shall refer to
standards from the Standards for Health Services in Prisons, National Commission on
Correctional Health Care (2003).
23

A “policy” is defined by the NCCHC as “a facility’s official position on a particular issue
related to an organization’s operations.” J-A-05; P-A-05.
24

A “procedure” is defined by the NCCHC as “describ[ing] in detail, sometimes in sequence,
how a policy is to be carried out.” J-A-05; P-A-05.

5

approved on September 3, 2007 (60 days after the State’s submission to the DOJ). The DOJ
supplied comments regarding the State’s draft policies on August 30, 2007. The State submitted
its revised draft policies to the DOJ on October 18, 2007. The DOJ approved those policies on
November 6, 2007. The State has several more policies regarding mental health that it is in the
process of drafting. In addition, the State now must promulgate procedures for each facility to
assist with the implementation of the policies.
In addition to the provision of the MOA requiring policies and procedures
regarding intake, communicable disease screening, sick call, chronic disease management, acute
care, infection control, infirmary care, and dental care, various other provisions of the MOA
contain specific requirements for policies and procedures. Specifically, the following paragraphs
contain a requirement for policies and procedures: 4 (medication and laboratory orders); 15 (drug
and alcohol withdrawal); 16 (pregnant inmates); 19 (access to medical and mental health
services); 21 (grievances), 23 (immunizations); 24 (medication administration); 31
(administration of mental health medications); 33 (mental health screening); 34 (mental health
assessment and referral); 39 (procedures for mentally ill inmates in isolation or observation
status); 44 (mental health intake screening/assessment); 48 (communication); 50 (observation);
52 (intervention); 53 (mortality and morbidity review); 54 (policies and procedures for quality
assurance); and 55 (corrective action plans). This report will address those requirements for
policies in occasion in the text of the report.
C.

Assessment

The State has made significant progress with regard to this provision of the MOA,
and therefore, the Monitoring Team found that the State is in partial compliance with this
provision.
3.

Record-Keeping
A.

Relevant MOA Provision
Paragraph 3 of the MOA provides:
The State shall develop and implement a unitary record-keeping system to
ensure adequate and timely documentation of assessments and treatment
and adequate and timely access by medical and mental health care staff to
documents that are relevant to the care and treatment of inmates. A unitary
record-keeping system consists of a system in which all clinically
appropriate documents for the inmate’s treatment are readily available to
each clinician. The State shall maintain a unified medical and mental
health file for each inmate and all medical records, including laboratory
reports, shall be timely filed in the medical file. The medical records unit
shall be adequately staffed to prevent significant lags in filing records in
an inmate’s medical record. The State shall maintain the medical records
such that persons providing medical or mental health treatment may gain
access to the record as needed. The medical record should be complete,

6

and should include information from prior incarcerations. The State shall
implement an adequate system for medical records management.
This provision of the MOA contains several key elements. First, the State must
develop and implement a unitary record-keeping system. According to the MOA, a unitary
record-keeping system consists of a system in which all clinically appropriate documents for an
inmate’s treatment are readily available to each clinician, and should include information from
prior incarcerations. Although the amount and type of documentation that should be in an
inmate’s health record is determined by the individual inmate’s medical history and condition, an
inmate’s health record normally should contain the following categories of documents:
•

identifying information (e.g., name, identification number, date of birth,
gender);

•

problem list containing medical and mental health diagnoses and treatment
as well as known allergies;

•

receiving screening and health assessment forms (see discussion of
provisions 10 and 12 of the MOA, infra);

•

progress notes of all significant findings, diagnoses, treatments, and
dispositions;

•

provider orders for prescribed medication;

•

medication administration records (“MARs”);

•

reports of laboratory, x-ray, and diagnostic studies;

•

flow sheets;

•

consent and refusal forms;

•

release of information forms;

•

results of specialty consultations and off-site referrals;

•

discharge summaries of hospitalizations and other inpatient stays;

•

special needs treatment plan, if applicable;

•

immunization records, if applicable;

•

place, date, and time of each clinical encounter; and

7

•

signature and title of each documenter.

J-H-01; P-H-01. A health record of this magnitude will not always be established for every
inmate; however, any health intervention after the receiving screening will require the initiation
of a record containing some or all of the foregoing documents. Id.
The MOA also requires that the State ensure that adequate staffing is maintained
to support medical records filing. Specifically, the State should maintain sufficient staffing so
that appropriate medical records are filed properly, and quickly enough so that staff can access
relevant information as needed. One requirement implicit in this provision of the MOA is that
the staff performing medical record-keeping functions be adequately trained to do so.
The DOC uses a paper medical records system, rather than electronic medical
records. However, some information generated for the paper record is initially recorded in the
DACS. DACS contains multiple “modules,” and is used by the DOC for many non-medical
tasks. Although DACS contains a medical module, the DOC reports that it was not designed to
be (and has not been) used as an electronic medical record. Until recently, the DACS medical
module was used mostly for certain intake and scheduling tasks.
The State began working with the DACS software vendor in April 2006 to
improve 178 medical module functions. See DOC Action Plan, Section II.3a. The DOC
implemented these upgrades on October 8, 2007, and reports that training on the upgrades is
ongoing. The Monitoring Team concluded that the DACS upgrades have the potential to assist
the state in obtaining more complete health information for inmates’ medical records; however,
the State should ensure that information collected and maintained in DACS is printed and
incorporated in the paper medical record promptly and properly.
There are several observations that apply to all of the Facilities:
•

The Facilities maintain separate infirmary and outpatient records. This
practice is not inconsistent with generally accepted professional standards,
however, the Monitoring Team observed that patients’ infirmary and
outpatient charts are not being maintained properly. Records regarding a
patient’s stay in the infirmary should be maintained in the infirmary
record, and once the patient’s stay in the infirmary is finished, that
infirmary record should be filed in the patient’s outpatient record. The
Monitoring Team found that filing of records at the Facilities is not
consistent with that practice.

•

The Facilities are failing to maintain inmate files in an organized fashion.
For example, the Monitoring Team found that some records are filed in
the incorrect portion of inmates’ health records, which means that unless a
clinician searches the entire health record, he or she will not be aware of a
patient’s entire history.

8

•

As will be discussed below in reference to HRYCI, the DOC has problems
with medical records being maintained properly in light of intrasystem
transfers.25
The Monitoring Team recommends that the DOC
conspicuously note in the front of, or in some other prominent place in, the
chart every transfer from one facility to another so that the dates of stay at
each location are clear. J-H-01; P-H-01. In addition, the inmate’s entire
health record needs to be transferred to the new facility so that the health
care providers at that facility can have complete information regarding the
inmate.

•

Improper or nonexistent filing of MARs is a consistent problem. The
Monitoring Team found that all of the Facilities had difficulty in ensuring
that these documents are filed properly and in a timely fashion.

The Facility-specific assessments are as follow:
B.

Baylor
1.

Findings

The Monitoring Team’s findings at Baylor are consistent with the global findings
mentioned above. The Monitoring Team found that documentation for patients in the infirmary
sometimes occurred in the patient’s outpatient record instead of in the patient’s infirmary binder.
As a result, a clinician seeking information pertinent to a patient’s infirmary care would not find
all of the relevant information in the patient’s infirmary binder. Also, the Monitoring Team
noted that documentation of patients being treated by nurses pursuant to detoxification protocols
is kept in a separate book.
The Monitoring Team further found that notes are frequently filed out of
sequence, and that some records are filed under incorrect tabs within a patient’s health record.
As mentioned above, this problem makes it difficult for health care providers to access (or be
aware of) important medical information in a consistent and efficient manner.
The Monitoring Team found that some charts were missing MARs, and, upon
inspection, the Monitoring Team found some MARs in loose filing at the facility. Finally, at the
time of the Monitoring Team’s visit to Baylor to monitor this provision, the Monitoring Team
found that there was a backlog of filing extending back to May 2007. The Health Services
Administrator at Baylor informed the Monitoring Team that additional staff had been allocated
to alleviate the backlog.
2.

Assessment

25

An “intrasystem transfer” occurs when an inmate is transferred from one DOC correctional
facility to another.

9

The Monitoring Team found that Baylor is in partial compliance with this
provision of the MOA because a unified health record system is in place, but the implementation
of that system still needs improvement.
C.

DCC
1.

Findings

The Monitoring Team’s findings at DCC are consistent with the global findings
mentioned above. The Monitoring Team found that the manner in which documents are not filed
in an inmate’s health record was not consistent, and depended upon the opinion of the individual
who was filing the records rather than a uniform process. In addition, the Monitoring Team
found that there were not as many infirmary records as there were patients in the infirmary, and
that it was not immediately apparent (i.e., without opening a file) which file was an infirmary
record, and which file as an outpatient record. As a result, the Monitoring Team found that an
inmate’s infirmary records are sometimes filed in an inmate’s outpatient record.
The Monitoring Team found that, overall, there was some confusion about where
certain records should be filed, as evidenced by nurses’ sometimes ad hoc filing methods as
described in the preceding paragraph, and information the Monitoring Team learned through
discussions with mental health and nursing staff. Specifically, a mental health clinician believed
that mental health records were supposed to be filed in a patient’s outpatient record under all
circumstances, and the nursing staff stated that many times mental health records are kept in
hardback binders.
In addition to those problems discussed above, the Monitoring Team found that
staffing at DCC is not adequate to prevent significant lags in filing records in an inmate’s health
care record. Nurses are given the responsibility of managing the medical record-keeping in the
DCC infirmary. This type of arrangement is not necessarily inappropriate, but given that the
levels of nurse staffing in the DCC infirmary are inadequate to take on this type of responsibility,
this arrangement is not appropriate at DCC. The nursing staff at DCC is not able to adequately
maintain medical records and carry out their nursing duties. In light of the fact that CMS is
having difficulty hiring enough nurses to adequately provide medical and mental health care to
inmates, one solution to both the medical record-keeping problem and the overall nurse staffing
problem is to hire appropriately trained medical records staff to ensure proper medical recordkeeping and alleviate this additional clerical burden on the nurses at DCC.
2.

Assessment

The Monitoring Team found that DCC is in partial compliance with this provision
of the MOA because a unified health record system is in place, but the implementation needs
improvement.
D.

HRYCI
1.

Findings

10

HRYCI has significant problems with medical record-keeping. During their
October 2007 visit, the Monitoring Team found that hundreds of intake records26 had not been
incorporated into inmates’ health records after those inmates were transferred to the other
Facilities from HRYCI. The transferred records therefore did not contain the intake sheets and
other relevant documents. After the discovery of this problem, staff at HRYCI began culling
through thousands of records in an attempt to correct the problem.
The Monitoring Team also found that many medical record documents are not
getting filed in the medical record and clinicians cannot rely on the medical record representing
the complete number of medical record documents. The Monitoring Team discovered this
problem after multiple record reviews and discussions with clinicians. During the October 2007
visit, the Monitoring Team found random, loose laboratory reports, health care requests,
consultation requests and other documents scattered within boxes of archive records, and even in
the medical records room.
The Monitoring Team returned to HRYCI on November 12, 2007. At that time,
the Monitoring Team found that most of the medical record problems caused by not sending
newly created charts on to permanent institutions had been resolved. A policy had been in place
for over a month to send all new charts to the permanent institution for that respective inmate. As
a result of this transfer of a number files, the Monitoring Team was informed that some backlog
had been created at the other Facilities. Under such circumstances, a backlog is to be expected.
During the November 2007 visit, the Monitoring Team found remaining about
150 boxes of old medical records that still needed to be reviewed to determine whether the
patients are still in the system. If the inmates are still in the system, then those remaining boxes
will be sent to the appropriate facility. Those inmates that are not found to be in the system and
have not been since 2004 will have their records sent to the archive area. The Monitoring Team
also found 2 to 3 boxes of loose documents that had not yet been reviewed, and therefore, there
was not yet any information regarding their contents or what needed to be done with those
contents.
At the time of the November 2007 visit, the archive room at HRYCI contained the
files of inmates no longer found in the computerized system that tracks those individuals that are
currently under the jurisdiction of the DOC who have been in the system at some time since
2004. There were three boxes of documents in the archive room that were to be filed with
medical records. A computer search was conducted, and revealed that those documents
belonged to patients no longer in the system.

26

“Intake records” are those records that are created at the time an inmate is brought into one of
the Facilities, and a brief medical history is taken prior to the inmate being scheduled for a full
health assessment. Intake records are of special importance at HRYCI because of the high level
of intake conducted at that facility versus the other Facilities. Many inmates that go through the
intake process at HRYCI are transferred to other Facilities upon sentencing.
11

The Monitoring Team also learned that other DOC facilities not covered by the
MOA are sending unmarked documents to HRYCI, for staff at HRYCI to review and forward to
the appropriate facilities. This practice should be stopped, as it creates an additional burden for
HRYCI staff. The Monitoring Team recommends that other DOC programs determine where the
documents should be sent, and send them directly to the correct facility.
The Monitoring Team has been informed that CMS brought in some temporary
staff to go through the backlog of filing issues at HRYCI, but the temporary workers were
released without the task having been completed. The archive room also contains records that
have been alphabetized only through the letter “I.” The room contains records of people no
longer on the locator, but who have been in the system between 2004 and the current date.
2.

Assessment

The Monitoring Team found that HRYCI is in partial compliance with this
provision of the MOA.
E.

SCI
1.

Findings

The Monitoring Team’s findings at SCI are consistent with the global findings
mentioned above. Specifically, the Monitoring Team found records where the active volume did
not contain necessary information, such as the reception information. They also found numerous
records in which materials were filed in the wrong section and were sometimes chronologically
inconsistent. Theses inconsistencies make it difficult for a clinician to have all the necessary
information available in order to make an appropriate clinical decision for the patient.
Additionally, infirmary records and orders are scattered throughout the record and MARs are
frequently not filed in the charts, sometimes for periods as long as four months.
2.

Assessment

The Monitoring Team found that SCI is in partial compliance with this provision
of the MOA.
F.

Recommendations

The Monitoring Team makes the following recommendations for each of the
Facilities with regard to medical record-keeping: (i) hire a professional medical records staff to
provide leadership, supervision, and standardization to medical records policies and procedures;
(ii) hire medical records staff dedicated only to that task in order to relieve the nursing staff from
that clerical function; (iii) provide standardized inpatient binders sufficient for each bed in the
infirmary; (iv) ensure timely, consistent and standardized filing of all documents; (v) ensure that
the creation of additional binder volumes for a given inmate results in all necessary documents
being moved to the active file; and (vi) self-monitor for timeliness and standardization of filing.

12

In addition to the global recommendations, the Monitoring Team has the
following additional recommendations for HRYCI: (i) Medical Records staff needs to develop a
system to track the daily change log and move the appropriate records, MARs and medications to
newly assigned clinic areas, and (ii) staff at HRYCI must complete the process of bringing
HRYCI records up to date.
4.

Medication and Laboratory Orders
A.

Relevant MOA Provision
Paragraph 4 of the MOA provides:
The State shall develop and implement policies, procedures, and practices
consistent with generally accepted professional standards to ensure timely
responses to orders for medications and laboratory tests. Such policies,
procedures, and practices shall be periodically evaluated to ensure that
delays in inmates’ timely receipt of medications and laboratory tests are
prevented.

The MOA requires that the State develop policies, procedures, and practices
consistent with generally accepted professional standards to ensure timely responses to orders for
medications and laboratory tests. The State has adopted policies consistent with this requirement
of the MOA. See State Policy D-02 and D-04. The State has not yet completed its facilityspecific procedures. The implementation of this policy should ensure that inmates do not
experience unnecessary delays and interruptions to care due to physician orders for medications
and laboratory tests not being timely performed. See J-E-12; P-E-12. Finally, the MOA requires
that the policies, procedures, and practices be periodically evaluated to ensure that delays in
inmates’ timely receipt of medications and laboratory tests are prevented. The Monitoring Team
recommends that the State include this periodic review as a part of the Continuous Quality
Improvement Program. See discussion of provision 54 of the MOA, infra.
In general, when assessing this provision of the MOA, the Monitoring Team
reviewed five to ten records at each facility for each chronic disease being assessed in
conjunction with other provisions of the MOA. By doing so, the Monitoring Team was able to
review whether orders for medications and laboratory tests were being responded to in a timely
fashion.
B.

Baylor
1.

Findings

From a review of patients’ charts, the Monitoring Team found that laboratory
studies were not always performed prior to inmates’ chronic care visits. A timely laboratory
study would take place prior to a chronic care visit. In addition, health records and interviews
with staff demonstrated that medication and laboratory orders are not consistently transcribed
and implemented. Finally, the Monitoring Team found that patients being prescribed certain
psychotropic medications are not receiving timely follow-up laboratory studies.

13

The Monitoring Team noted several cases where the physician ordered various
studies or tests which were not completed, in one case as long a period as eight weeks elapsed
after the order. Furthermore, there were some cases where the tests were completed, but the
results were never obtained or noted.27 This finding is based on both a review of a limited
number of files (~5) and information consistent with this review provided by staff.
2.

Assessment

The Monitoring Team found that Baylor is in partial compliance with this
provision of the MOA.
C.

DCC
1.

Findings

The Monitoring Team found that physician orders for laboratory tests are not
consistently obtained at all, let alone in a timely manner. Specifically a review of health records
revealed that laboratory tests are not consistently obtained in a timely fashion, and sometimes are
not obtained at all. Interviews with staff revealed that emergency testing is sent to Kent General
Hospital, but results are not returned in a timely fashion. The Monitoring Team also found that
health records reflected that critical laboratory results were followed up several days after the
report. Such reports should be followed up the same day.
The Monitoring Team found that routine laboratory studies are generally performed in a
timely manner. However, it appears that laboratory studies that must be performed on an empty
stomach are delayed by about one to two weeks. In addition, the Monitoring Team noted that
there has been difficulty in obtaining laboratory samples from inmates housed in maximum
security.
A review of an internal audit performed by CMS revealed that there had been four
apparent failures to perform an ordered laboratory study. Specifically, the orders for the
laboratory studies were transcribed but there was no corresponding progress note in the inmates'
health records indicating that the laboratory study was done.
2.

Assessment

The Monitoring Team found that DCC is in partial compliance with this provision
of the MOA.
D.

HRYCI
1.

Findings

27

At various points during this report, the Monitoring Team will refrain from providing further
detail regarding a specific inmate due to confidentiality concerns.

14

The Monitoring Team found that, similar to DCC, physician orders for laboratory
tests are not consistently obtained at all, let alone in a timely manner. HRYCI lacks a system to
track laboratory testing, which results in laboratory testing not being adequately monitored or
supervised.
Regarding mental health tests and orders, lab results were reported to be in the
chart, but a significant number were ordered but never drawn, based on the December 6, 2007
audit. The Monitoring Team found that, according to staff, approximately one-third of the
ordered lab studies were refused by the inmate, but there was no information why the other twothirds were missing.
2.

Assessment

The Monitoring Team found that HRYCI is in partial compliance with this
provision of the MOA.
E.

SCI
1.

Findings

The Monitoring Team found that laboratory tests are rarely ordered, and those
that are consist primary of psychiatric medication level testing. Once the results of those
laboratory tests are reported, the Monitoring Team found that appropriate follow-up does not
occur.
The Monitoring Team noted several cases where the physician ordered various
studies or tests which were not completed, in one case as long a period as eight weeks elapsed
after the order. Furthermore, there were some cases where the tests were completed, but the
results were never obtained or noted.
2.

Assessment

The Monitoring Team found that SCI is in partial compliance with this provision
of the MOA.
F.

Recommendations

The Monitoring Team recommends that the State: (i) draft and implement
procedures to ensure timely receipt, review, and response to all laboratory orders; (ii) draft and
implement procedures to ensure timely response to emergency orders and “critical” values; and
(iii) self-monitor these procedures to ensure timeliness and appropriateness of medication and
laboratory orders.

15

STAFFING AND TRAINING
5.

Job Descriptions and Licensure
A.

Relevant MOA Provision
Paragraph 5 of the MOA provides:
The State shall ensure that all persons providing medical or mental health
treatment meet applicable state licensure and/or certification requirements,
and practice only within the scope of their training and licensure. The
State shall establish a credentialing program that meets generally accepted
professional standards, such as those required for accreditation by the
National Committee for Quality Assurance.

The first component of this provision of the MOA requires that all persons
providing medical or mental health services meet applicable state licensure and/or certification
requirements and practice only within the scope of their training and licensure. In addition, the
MOA requires that the State establish a credentialing program such as those required for
accreditation by the National Committee for Quality Assurance.
B.

Baylor
1.

Findings

The Monitoring Team found that appropriately trained and credentialed staff are
providing medical and mental health services.
2.

Assessment

The Monitoring Team found that Baylor is in substantial compliance with this
provision of the MOA.
C.

DCC
1.

Findings

The Monitoring Team found that not all of the physicians at DCC are practicing
within an appropriate scope of their training. Specifically, one physician is a pathologist, but
practices general medicine; another physician has completed only an internship, but has been
managing patients with both complicated and uncomplicated chronic illnesses. The Monitoring
Team believes that this is not an appropriate arrangement although it meets the standard set forth
in the MOA. It is the Monitoring Team’s experience from monitoring in other jurisdictions that
a disproportionate amount of bad outcomes have been found with physicians practicing primary
care medicine who have not successfully completed a primary care residency.

16

The Monitoring Team found that only two non-psychiatrist mental health
clinicians are appropriately licensed. As a result, although they have, for the most part, achieved
the required educational training, the remaining mental health clinicians must be supervised in
order to become licensed.28
The clinical supervision consists of weekly meetings, a weekly case review, and
informal daily interaction. This clinical supervision reportedly meets the criteria for supervised
practice under supervision to meet licensure criteria. Some of the mental health staff has shown
discomfort with this necessary level of scrutiny.
2.

Assessment

The Monitoring Team found that DCC is in partial compliance with this provision
of the MOA with regard to medical health staff licensure, and not in compliance with this
provision of the MOA with regard to mental health staff licensure.
D.

HRYCI
1.

Findings

The mental health clinical staffing is not adequate, as will be discussed below.
With respect to licensing, the Monitoring Team found that the mental health counselors at
HRYCI are not appropriately licensed. The mental health counselors have, for the most part,
completed the educational requirements; however, these counselors require approximately two
years of supervised practice, depending upon the specific license that the counselor intends to
obtain.
It was reported to the Monitoring Team by the mental health director that she
provides supervision for the unlicensed staff. The supervision was supposed to consist of
individual meetings of one hour per week, and one three-hour group meeting per month. Upon
investigation, the Monitoring Team found that these meetings may not be occurring as they were
reported.
2.

Assessment

The Monitoring Team did not assess HRYCI’s compliance with this provision of
the MOA with respect to the health services staff due to high staff turnover. While the
Monitoring Team did examine this issue when it visited HRYCI, given the high rate of turnover
it would be inappropriate to give an assessment rating at this time. The MOA requires that all

28

The State plans to ensure that all mental health clinicians are appropriately licensed by
December 2008. CMS is providing tuition reimbursement, and plans to retain unlicensed staff
members until December 2008 as long as the staff member is showing progress toward licensure.
The Monitoring Team found that because some staff will have to obtain an additional master’s
degree to qualify to licensure, their future employability might have become an issue.
17

medical and mental health staff be appropriately licensed. Given the rate of turnover of staff at
HRYCI, the Monitoring Team is unable to assess the State’s compliance.
With respect to mental health services staff, the Monitoring Team found that
HRYCI is not in compliance with this provision of the MOA.
E.

SCI
The Monitoring Team did not assess SCI’s compliance with this provision of the

MOA.
F.

Recommendations

The Monitoring Team recommends the following with respect to all facilities in
order to address situations involving turnover of staff. The State should forward to the
Monitoring Team copies of relevant licensing materials for all newly hired medical and mental
health staff. By doing so, the Monitoring Team will be able to give an assessment of a facility
even if there is a high turnover of staff after the Monitoring Team’s visit.
The Monitoring Team offers additional recommendations regarding this provision
of the MOA for DCC and HRYCI. At DCC, the Monitoring Team recommends that the State
ensure that all primary care providers have completed a primary care residency. Also, the
Monitoring Team recommends that the State create a plan to ensure that all positions are staffed
with appropriately credentialed professionals.
At HRYCI, the Monitoring Team recommends that the State: (i) create a plan
that ensures ongoing, direct supervision of service provided by unlicensed staff; and (ii) ensure
that all staff members who require licenses obtain them in a timely fashion.
6.

Staffing
A.

Relevant MOA Provision
Paragraph 6 of the MOA provides:
The State shall maintain sufficient staffing levels of qualified
medical staff and mental health professionals to provide care for
inmates’ serious medical and mental health needs that meets
generally accepted professional standards.

One way to evaluate the adequacy and effectiveness of a Facility’s staffing plan is
the Facility’s ability to meet the health needs of the inmate population. J-C-07; P-C-07. Various
factors can be examined to determine the number and type of health care professionals required
at a facility, such as the: (i) size of the facility; (ii) types and scope of health services delivered;
(iii) needs of the inmate population at the particular facility, and (iv) organizational structure of
the facility. Id. In addition, two other factors of significance in evaluating the sufficiency of

18

staffing levels are whether a prescribing provider29 is available for a sufficient amount of time so
as to avoid any unreasonable delay in patients receiving necessary care, and if physician time30 is
sufficient to meet both clinical31 and administrative responsibilities.32 Id.
B.

Baylor
1.

Findings

The Monitoring Team found that both physician and nursing staff time is
inadequate given the missions and size of Baylor.33 The Monitoring Team found problems at
Baylor that are symptomatic of a nursing shortage. Specifically, physician orders were not being
performed and laboratory tests were not prepared in a timely fashion for clinician appointments.
Another example of inadequate nursing assistance is that the nurse practitioner does not have a
nurse assigned to assist her during appointments with pregnant women. These staffing shortages
create systemic problems that have the potential to result in providers being impeded in
rendering adequate health care to patients.
The Monitoring Team found that the physician and primary nurse practitioners
are very conscientious. It is only through their extra efforts that patients at Baylor usually are
receiving the care that they need.
With respect to mental health staffing, the Monitoring Team observed that the
staffing was adequate to assess new intakes to Baylor, see crisis patients, and complete isolation
29

A “prescribing provider’ is defined as “a licensed individual, such as an medical doctor, doctor
of osteopathy, nurse practitioner, or physician’s assistant, authorized to write prescriptions. J-C07; P-C-07.
30

Typically, 3.5 hours of physician time per 100 inmates housed at a facility is regarded as the
minimum acceptable physician time. J-C-07; P-C-07. Nurse practitioners or physician’s
assistants may substitute for a portion of the physician’s time seeing patients, but must do so
under the supervision of a physician. Id.; see generally, 24 Del. C. § 1772.
31

Clinical responsibilities include conducting physical examinations, evaluating and managing
parties in clinics, monitoring other providers by reviewing and co-signing charts, reviewing
laboratory and other diagnostic test results, and developing individual treatment plans. J-C-07;
P-C-07.
32

Administrative responsibilities include reviewing and approving policies, procedures,
protocols, and guidelines, participating in staff meetings, conducting in-service training program,
and participating in quality improvement and infection control programs. J-C-07; P-C-07.

33

Nursing shortages are being experienced throughout the United States, including Delaware.
Thus, it is difficult for the State to recruit nurses to work in correctional facilities. The State
believes that it is especially difficult to recruit qualified nurses for HRYCI due to the large
number of employers aggressively recruiting for those same nurses.
19

rounds and suicide observation. Beyond this basic level of services, however, very limited
mental health services are being offered at Baylor. Given the number of monthly contacts per
counselor, it is not possible for that much psychotherapy to be delivered. The mental health staff
at Baylor was very new at the time of the Monitoring Team’s visit regarding this provision of the
MOA. Specifically, new staff had been hired between the Monitoring Team’s visits in July and
October, the temporary mental health supervisor had left, and the new director was to begin the
same week of the Monitoring Team’s October 2007 visit to Baylor. As a result of these changes
around the time of the Monitoring Team’s visit, the Monitoring Team found that it is premature
to judge their level of efficiency.
CMS has reallocated a Director of Nurses position, three LPN’s and a clerical
position to Baylor, which provides support to the partial compliance assessment.
2.

Assessment

The Monitoring Team found that Baylor is in partial compliance with this
provision of the MOA.
C.

DCC
1.

Findings

With respect to physician staffing, the Monitoring team found that the physician
to inmate ratio (1:650) generally would be sufficient; however, given needs of the inmate
population at DCC, physician staffing is not adequate. Specifically, DCC houses the sickest
inmates within the State’s correctional system in its infirmary, and has a special needs unit with a
large number of inmates with disabilities, chronic illnesses, or other issues that cause them to
need more attention from health care staff.
With respect to nurse staffing, the Monitoring Team found that the number of
nurses allocated to medication administration and the level of nurse staffing in the infirmary is
inadequate. Specifically, in the infirmary, there are two nurses and one medical assistant
assigned to an infirmary unit with a capacity of 44 inmates, which is often at or near capacity.
Patients in this infirmary are either ones that would require a nursing home if they were in the
community, or ones that have some acute problem that requires careful attention. Several of the
patients in the infirmary are either partially or totally dependent on nurses because they are
unable to care for themselves. The infirmary also houses a few patients who are incontinent, one
of whom is very large and requires multiple staff to move him so that he and his bed can be
cleaned.
The two nurses and one medical assistant assigned to the infirmary must
administer medication, perform physician order assignments, perform health assessments,
perform admissions and discharges, make rounds, document progress notes and other items in
patients’ charts, perform patient cleaning and hygiene assistance for all of these patients. The
fact that staffing of this infirmary is insufficient is evident by the lack of nurse documentation in

20

patient charts. The burden on these employees could be lessened somewhat if they were relieved
of their medical record-keeping and cleaning duties.
The Monitoring Team found that mental health staffing is not adequate due to
licensure, supervision, and vacancy issues. Specifically, ten of the clinicians are unlicensed.
One Special Housing Unit (“SHU”) counselor position is vacant due to a suspension in
December 2007, and another clinician is on leave, resulting in that position being functionally
vacant. While the psychiatrist nurse position is filled, the person holding that position is also on
leave, resulting in this position being as well functionally vacant.
2.

Assessment

The Monitoring Team found that DCC is in partial compliance with this provision
of the MOA with regard to medical staffing, and not in compliance with regard to mental health
staffing.
D.

HRYCI
1.

Findings

One significant problem that the Monitoring Team found at HRYCI relates to
maintaining adequate numbers of qualified nursing staff to provide health care to the inmate
population. Additionally, there is a significant problem with staff not coming to work as
scheduled, and staff insubordination. The Health Services Administrator and the Director of
Nursing are attempting to alleviate these problems.
If staff is not showing up for work or performing adequately, although a sufficient
number of positions might be filled, the State’s ability to come into compliance with this
provision of the MOA might be impaired because the adequacy of care could continue to be
hampered in spite of sufficient staffing levels. These issues compound the overall difficulty with
nurse recruiting due to nurse shortages.
With respect to mental health staffing, the Monitoring Team found that the
staffing is inadequate to provide the depth of services necessary.34 In general, the mental health
services that the staff is able to provide amounts to welfare checks.
2.

Assessment

The Monitoring Team found that HRYCI is in partial compliance with this
provision of the MOA.
E.

SCI

34

Recently, the mental health supervisor resigned, and one of the psychiatrist’s contracts was
terminated for cause.
21

1.

Findings

The Monitoring Team found that physician and nursing staffing is inadequate.
The Monitoring Team found that one of the doctors at SCI is also assigned to act as the statewide
HIV doctor, which causes him to have less time to spend at SCI. The physician is not providing
leadership and supervision to all of the clinical staff. Also, the Monitoring Team found that the
number of available nurses was not adequate to cover necessary duties at SCI, and there is no
chronic disease nurse, which would be helpful given the characteristics of SCI. The lead nurse
and the Health Services Administrator provide coverage for general nursing duties that would
otherwise be carried out by others.
The Monitoring Team found that most of the mental health positions have been
filled, which has allowed for SCI to begin providing more services above and beyond the bare
minimum. SCI offers clinical mental health services between 8:30 a.m. and 8:00 p.m. during the
workweek. The clinical mental health services consist of individual encounters and some group
programming, although lack of space presents an obstacle to the mental health staff’s ability to
provide such services.
2.

Assessment

The Monitoring Team found that SCI is in partial compliance with this provision
of the MOA.
F.

Recommendation

At DCC, the Monitoring Team recommends that the State ensure that all primary
care providers have completed a primary care residency. In addition, the Monitoring Team
recommends that the State perform a staffing analysis regarding numbers of staff by discipline
needed per shift to adequately meet the nursing needs of a full infirmary and perform medication
administration. Finally, the Monitoring Team recommends that the State conduct a staffing
analysis for mental health professionals with descriptions of the duties by discipline and shift.
At HRYCI, the Monitoring Team recommends that the leadership should continue
to hold staff accountable for performance issues. The addition of nursing supervisory staff
should assist with this issue. In addition, the Monitoring Team recommends that the State create
a plan to fill all mental health positions at HRYCI and the Central Office within a reasonable
timeframe. Currently there are 1.5 full time equivalent (“FTE”) mental health clinical staff
allocations which are vacant.
At Baylor and SCI, the Monitoring Team recommends performing staffing
analyses that address the issues raised in findings, and ensures timely provision of services and
compliance with policies and procedures.
7.

Medical and Mental Health Staff Management
A.

Relevant MOA Provision

22

Paragraph 7 of the MOA provides:
The State shall ensure that a full-time medical director is responsible for
the management of the medical program. The State shall also provide a
director of nursing and adequate administrative medical and mental health
management. In addition, the State shall ensure that a designated clinical
director shall supervise inmates’ mental health treatment at the Facilities.
These positions may be filled either by State employees, by independent
contractors retained by the State, or pursuant to the State's contract with a
correctional health care vendor.
According to NCCHC Standards for both jails and prisons, each of the Facilities
should have a designated health authority responsible for health care services and, as provided in
the MOA, each of the Facilities should have another responsible health authority for mental
health services. J-A-02; P-A-02. According to the State’s Action Plan, positions that State plans
to fill in order to meet this requirement are a statewide full-time medical director, statewide
director of nursing, a statewide full-time mental health director as well as additional
administrative management staff to assist the foregoing state-level positions. See Section 7 of
the State’s Action Plan. In addition, there is a position at each of the Facilities for a clinical
director of mental health, a Health Services Administrator, medical director and director of
nursing. For a Facility to be in substantial compliance with this provision of the MOA, the
Monitoring Team needs to find that there has been stable and quality leadership at the Facility.
Thus, simply filling a position will not be adequate.
B.

Baylor
1.

Findings

While the position is filled for the on-site medical director, documentation was
not received by the Monitoring Team to describe the site responsibilities of the medical director.
Thus, the Monitoring Team was unable to evaluate whether the medical director would meet the
applicable standard. Also, the administrative support for medical and mental health management
clinicians has not been adequate, as evidenced by the clinicians creating their own backup
systems to ensure that care is timely. By “backup system” the Monitoring Team is referring to
the physician keeping her own notebook containing scheduling for offsite appointments. While
this practice shows the conscientiousness of this particular physician, the Monitoring Team
believes the physician should not be doing this sort of clerical work and it demonstrates the
inadequacy of the support infrastructure at Baylor.
The Monitoring Team found that there has been high turnover in the mental
health director position at Baylor. The mental health director who had been at Baylor for a long
time resigned in 2007. A new mental health director was moved from a position at DCC to
Baylor in August 2007, but resigned effective October 31, 2007. A new mental health director is
in place at Baylor who previously worked at HRYCI. Based on interviews with the new mental
health director and staff, as well as a review of the overall organization with health care services
delivery systems at Baylor indicated to the Monitoring Team that the new mental health director
23

can be an effective leader and administrator, but the Monitoring Team believed it was premature
to make that determination.
2.

Assessment

The Monitoring Team found that Baylor is in partial compliance with this
provision of the MOA.
C.

DCC
1.

Findings

The Monitoring Team found that, at the time of the visit to DCC to assess this
provision of the MOA, DCC did not have a single medical director. Instead, CMS had assigned
the title of medical director to two physicians. This arrangement is not working because the staff
do not uniformly recognize who the medical director is and as a result there is confusion and a
lack of direction. A single person should be designated as a medical director. This assignment
should be clear to all staff and should result in that person having clinical leadership of the
program.
The Monitoring Team found that DCC had a designated mental health director
who administratively supervises inmates’ mental health treatment. The mental health director
was new at the time of the Monitoring Team’s visit to monitor this provision of the MOA. Thus,
it is premature to make an assessment as to the adequacy of the new mental health director.
Based upon interviews with the mental health director, staff, and a review of the overall
organization of mental health services delivery systems, the Monitoring Team believes that the
present mental health director will be an effective leader.
2.

Assessment

The Monitoring Team found that DCC is not in compliance with this provision of
the MOA with respect to medical healthcare management, and that DCC is in partial compliance
with respect to mental healthcare management.
D.

HRYCI
1.

Findings

The Monitoring Team found that turnover among leadership positions has been
much higher than a good organization can tolerate. The Health Services Administrator that is in
place has been at HRYCI for approximately five months, and the director of nursing for a shorter
period of time. Before these individuals were hired, turnover in these positions was a serious
problem. All of the inconsistency in medical health services management has led to inhibited
growth of program development, and a lack of adequate supervision and leadership has appeared
in the performance of medical staff. The Monitoring Team is hopeful that the current Health
Services Administrator and director of nursing will stay and continue to provide HRYCI with

24

stability and leadership. The on site medical director position was not filled at the time the
Monitoring Team monitored this provision of the MOA.35 Finally, there was a lack of adequate
nurse supervisors.

HRYCI.
treatment.

A mental health director is in place at HRYCI, and has been a stable presence at
This mental health director administratively supervises inmates’ mental health

2.

Assessment

The Monitoring Team found that HRYCI is in partial compliance with this
provision of the MOA.
E.

SCI
1.

Findings

While the primary physician and psychiatrist are in place, the Monitoring Team
found that neither provides very strong leadership or meaningful peer review.
2.

Assessment

The Monitoring Team found that SCI is in partial compliance with this provision
of the MOA.
F.

Recommendations

The Monitoring Team recommends that the State take the following actions at
Baylor: (i) implement systems to ensure that support results in timely services consistent with
the policies and procedures; and (ii) provide psychiatric peer review regarding clinical
performance and documentation.
The Monitoring Team recommends that the State take the following actions at
DCC: (i) delineate Medical Director responsibilities and, if necessary, Assistant Medical
Director duties; and (ii) ensure that the staffing plan allows for both direct clinical service hours
and hours for administrative and supervisory functions.
The Monitoring Team recommends that the State take the following actions at
HRYCI: (i) CMS should establish and fill nursing supervisor positions to provide 24-7 nursing
supervisory coverage; and (ii) CMS should hire an on-site medical director, thus allowing the
State Medical Director to resume his other duties.

35

In fact, at that time, the lead physician had just been terminated for performance deficiencies.

25

The Monitoring Team recommends that the State take the following actions at
SCI: (i) create a plan to improve clinical leadership over the Medical program; and (ii) create a
plan that addresses concerns raised in the Findings.
8.

Medical and Mental Health Staff Training
A.

Relevant MOA Provision
Paragraph 8 of the MOA provides:
The State shall continue to ensure that all medical staff and mental health
professionals are adequately trained to meet the serious medical and
mental health needs of inmates. All such staff shall continue to receive
documented orientation and in-service training in accordance with their
job classifications, and training topics shall include suicide prevention and
the identification and care of inmates with mental disorders.

Adequate training for medical and mental health staff includes an immediate basic
orientation36 and all full-time staff must complete a formal in-depth orientation37 to the health
services program at a facility. J-C-09; P-C-09.
B.

Baylor

36

A “basic orientation” is one that “is provided on the first day of employment, includes
information necessary for the health staff member (e.g., full-time, part-time, consultant, per
diem) to function safely in the institution.” J-C-09-; P-C-09. At a minimum, the basic
orientation should include relevant security and health services policies and procedures, response
to facility emergency situations, the staff member’s functional position description, and inmatestaff relationships. Id.
37

An “in-depth orientation” should occur within 90 days of employment, and includes “a full
familiarization with the health services delivery system at the facility, and focuses on the
similarities as well as the differences between providing health care in the in community and in a
correctional setting.” J-C-09-; P-C-09. Specifically, at a minimum, the curriculum of the indepth orientation should include all health services policies and procedures not addressed in the
basic orientation, health and age-specific needs of the inmate population, infection control
including use of standard precautions, and confidentiality of records and health information. Id.
In addition to these essential topics, a formal orientation program could include the following
topics: (i) security, including classification of inmates; (ii) health care needs of the inmate
population; (iii) the inmate social system; (iv) the organization of health services at the facility;
and (v) infection control. Id. For nursing staff, topics could also include: (i) assessment and
sick-call triage; (ii) emergency triage and management; (iii) resource utilization outside the
facility; (iv) procedures for release of information; (v) expected documentation practices; (vi)
isolation procedures; and (vii) professional boundaries. Id.
26

The Monitoring Team did not assess Baylor’s compliance with this provision of
the MOA.
C.

DCC
1.

Findings

The Monitoring Team found that staff training consists of an orientation, basic
life support and cardiopulmonary resuscitation (“CPR”), an eight-hour presentation on suicide
prevention sponsored by the State, and a four-hour presentation on suicide prevention sponsored
by CMS. In addition, staff receives a 16-hour presentation course in emergency preparedness.
The Monitoring Team found that all of the staff have completed the required training, with the
exception of a psychiatrist who was hired in November 2007.
2.

Assessment

The Monitoring Team did not assess DCC’s compliance with this provision of the
MOA with respect to the medical staff. The Monitoring Team found that DCC is in substantial
compliance with this provision of the MOA with respect to mental health staff.
D.

HRYCI
1.

Findings

The Monitoring Team found that staff training consists of an orientation, basic
life support and cardiopulmonary resuscitation (“CPR”), an eight-hour presentation on suicide
prevention sponsored by the State, and a four-hour presentation on suicide prevention sponsored
by CMS. In addition, staff receives a 16-hour presentation course in emergency preparedness.
2.

Assessment

The Monitoring Team did not assess HRYCI’s compliance with this provision of
the MOA with respect to the medical staff. The Monitoring Team found that HRYCI is in
substantial compliance with this provision of the MOA with respect to mental health staff.
E.

SCI
The Monitoring Team did not assess SCI’s compliance with this provision of the

MOA.
9.

Security Staff Training
A.

Relevant MOA Provision
Paragraph 9 of the MOA provides:

27

The State shall ensure that security staff are adequately trained in the
identification, timely referral, and proper supervision of inmates with
serious medical or mental health needs. The State shall ensure that security
staff assigned to mental health units receive additional training related to
the proper supervision of inmates suffering from mental illness.
Adequate training for security staff should occur at least every two years, and
include, at a minimum, the following topics: (i) the administration of first aid; (ii) recognizing
the need for emergency care and intervention in life-threatening situations (e.g. a heart attack);
(iii) recognizing acute manifestations of certain chronic illnesses, intoxication and withdrawal,
and adverse reactions to medications; (iv) recognizing signs and symptoms of mental illness; (v)
procedures for suicide prevention; (vi) procedures for appropriate referral of inmates with health
complaints to health staff; (vii) precautions and procedures with respect to infectious and
communicable diseases; and (viii) CPR. J-C-04; P-C-04. At any given time, at least 75% of the
security staff present should be current with their health-related training. Id. The Facilities
should maintain a certificate or other evidence of security staff’s training, and an outline of the
course content and the length of the course for the Monitoring Team’s review to assess the
appropriateness of the health-related training. Id.
B.

Baylor

1.

Findings

The Monitoring Team found that every new member of the security staff attends a
three-hour general overview regarding mental illness as a cadet in the academy, and these hours
are tracked on a statewide basis. Also, each new member of the security staff attends an eighthour course regarding suicide prevention training, and then that training is repeated at the
facility-level. The Statewide training completion date regarding suicide prevention training for
all personnel occurred on September 30, 2007. The training officer at the facility-level tracks
these hours. The most current count available to the Monitoring Team at the time of their visit
was that 99% of security staff had completed the training. Finally, the State is working on a
refresher requirement that DOC is working on with their Employee Development Center. See
State Policy C-04.
2.

Assessment

The Monitoring Team did not assess Baylor’s compliance with this provision of
the MOA with respect to training security staff regarding non-mental health medical topics. The
Monitoring Team found Baylor to be in substantial compliance with this provision of the MOA
with respect to training security staff regarding mental health topics.
C.

DCC
1.

Findings

28

The Monitoring Team found that every new member of the security staff attends a
three-hour general overview regarding mental illness as a cadet in the academy, and these hours
are tracked on a statewide basis. Also, each new member of the security staff attends an eighthour course regarding suicide prevention training, and then that training is repeated at the
facility-level. The Statewide training completion date regarding suicide prevention training for
all personnel occurred on September 30, 2007. The training officer at the facility-level tracks
these hours. The most current count available to the Monitoring Team at the time of their visit
was that 99% of security staff had completed the training. Finally, the State is working on a
refresher requirement that DOC is working on with their Employee Development Center. See
State Policy C-04.
2.

Assessment

The Monitoring Team did not assess DCC’s compliance with this provision of the
MOA with respect to training security staff regarding non-mental health medical topics. The
Monitoring Team found DCC to be in substantial compliance with this provision of the MOA
with respect to training security staff regarding mental health topics.
D.

HRYCI
1.

Findings

The Monitoring Team found that every new member of the security staff attends a
three-hour general overview regarding mental illness as a cadet in the academy, and these hours
are tracked on a statewide basis. Also, each new member of the security staff attends an eighthour course regarding suicide prevention training, and then that training is repeated at the
facility-level. The Statewide training completion date regarding suicide prevention training for
all personnel occurred on September 30, 2007. The training officer at the facility-level tracks
these hours. The most current count available to the Monitoring Team at the time of their visit
was that 99% of security staff had completed the training. Finally, the State is working on a
refresher requirement that DOC is working on with their Employee Development Center.38 See
State Policy C 04.
2.

Assessment

The Monitoring Team did not assess HRYCI’s compliance with this provision of
the MOA with respect to training security staff regarding non-mental health medical topics. The
Monitoring Team found HRYCI to be in substantial compliance with this provision of the MOA
with respect to training security staff regarding mental health topics for the same reasons cited
above with regard to DCC.
E.

SCI

38

The Employee Development Center provides training to DOC correctional staff. Thus, if the
Employment Development Center causes topics or courses to become part of its required
curriculum, correctional staff should receive the training at adequate rates.
29

1.

Findings

The Monitoring Team found that every new member of the security staff attends a
three-hour general overview regarding mental illness as a cadet in the academy, and these hours
are tracked on a statewide basis. Also, each new member of the security staff attends an eighthour course regarding suicide prevention training, and then that training is repeated at the
facility-level. The Statewide training completion date regarding suicide prevention training for
all personnel occurred on September 30, 2007. The training officer at the facility-level tracks
these hours. The most current count available to the Monitoring Team at the time of their visit
was that 99% of security staff had completed the training. Finally, the State is working on a
refresher requirement that DOC is working on with their Employee Development Center.39 See
State Policy C 04.
2.

Assessment

The Monitoring Team did not assess SCI’s compliance with this provision of the
MOA with respect to training security staff regarding non-mental health medical topics. The
Monitoring Team found SCI to be in substantial compliance with this provision of the MOA
with respect to training security staff regarding mental health topics for the same reasons cited
above with regard to DCC.

39

The Employee Development Center provides training to DOC correctional staff. Thus, if the
Employment Development Center causes topics or courses to become part of its required
curriculum, correctional staff should receive the training at adequate rates.
30

SCREENING AND TREATMENT
10.

Medical Screening
A.

Relevant MOA Provision
Paragraph 10 of the MOA provides:
The State shall ensure that all inmates receive an appropriate and timely
medical screening by a medical staff member upon arrival at a facility.
The State shall ensure that such screening enables staff to identify
individuals with serious medical or mental health conditions, including
acute medical needs, infectious diseases, chronic conditions, physical
disabilities, mental illness, suicide risk, and drug and/or alcohol
withdrawal. Separate mental health screening shall be provided as
described in Paragraph 34 [of the MOA].

According to NCCHC standards, timely receiving screening40 means that the
screening performed on inmates immediately41 upon arrival at the respective intake facility, and
is performed by a qualified health care professional or a health-trained person. J-E-02; P-E-02.
The policies adopted by the State provide that such receiving screening will be initiated within
two hours of arrival into a facility and will be the responsibility of the nursing healthcare staff.
See State Policy E-02. This policy is adequate. If a receiving screening is completed within
three to four hours of arrival to a Facility, the Monitoring Team believes that is reasonable.
The MOA requires that the State ensure that the receiving screening, “enables
staff to identify individuals with serious medical or mental health conditions, including acute
medical needs, infectious diseases, chronic conditions, physical disabilities, mental illness,
suicide risk, and drug and/or alcohol withdrawal.” In order to comply with this requirement, the
State should ensure that receiving personnel are making consistent and complete inquiries and
40

A “receiving screening” is
[A] process of structured inquiry and observation designed to prevent newly arrived
inmates who pose a threat to their own or others’ health or safety from being admitted to
the facility’s generally population, and to get them rapid medical care. It is intended to
identify potential emergency situations among new arrivals to the facility, and also to
ensure that those patients with known illnesses and currently on medications are
identified for further assessment and continued treatment.

J-E-02; P-E-02. In sum, the purpose of a receiving screening is to (i) identify and meet any
urgent health needs of those admitted; (ii) identify and meet any known or easily identifiable
health needs that require medical intervention before the health assessment (see infra); and (iii)
identify and isolate inmates who appear potentially contagious. Id.
41

NCCHC standards do not clarify what is meant by “immediately.” The Monitoring Team
believes that 3 to 4 hours is reasonable.
31

observations. Reception personnel should use a checklist to ensure that they inquire about the
following important information:
•

current and past illnesses, health conditions, or special health requirements
(e.g. dietary needs);

•

past serious infectious disease(s);

•

recent communicable illness symptoms (e. g. chronic cough, coughing up
blood, lethargy, weakness, weight loss, loss of appetite, fever, night
sweats);

•

past or current mental illness, including hospitalizations;

•

history of or current suicidal ideation;

•

dental problems;

•

allergies;

•

legal an illegal drug use (including the last time of use);

•

drug withdrawal symptoms;

•

current or recent pregnancy; and

•

other health problems that the State should decide to include on its form.

J-E-02; P-E-02. In addition, reception personnel should note on the receiving screening form
observations:
•

appearance (e.g. sweating, tremors, anxious, disheveled);

•

behavior (e.g., disorderly, appropriate, insensible);

•

state of consciousness (e.g., alert, responsive, lethargic);42

•

ease of movement (e.g. body deformities, gait);

42

Persons who are unconscious, semi-conscious, bleeding, mentally unstable, or otherwise
urgently in need of medical attention upon arriving at a Facility should be referred immediately
for care. J-E-02; P-E-02. Such an immediate referral upon arrival at a Facility should be noted
on the receiving screening form. Id. In addition, if the inmate is referred to a community
hospital for care of the emergency condition and are returned the Facility should require a
written medical clearance from the community hospital. Id.

32

•

breathing (e.g. persistent cough, hyperventilation); and

•

skin (e.g. lesions, jaundice, rashes, infestations, bruises, scars, tattoos, and
needle marks or other indications of drug abuse).

Id. The disposition of the inmate (i.e., if the inmate was immediately referred for medical care,
or placed in general population, etc.) should be indicated on the receiving screening form. Id.
Once the receiving screening form has been completed, it should include the date and time of
completion, and the signature and title of the person completing the form. Id. Finally, the
receiving screening should allow for all immediate health needs to be identified and addressed,
and potentially infectious inmates to be isolated. Id.
As noted above, the State has created a policy stating that a receiving screening
will be initiated within two hours of arrival to a Facility. See State Policy E-02. This policy
further provides that inmates will be screened in a manner consistent with the NCCHC standards
cited above. Id. Also, the State will record the findings of the screenings in DACS, and that the
screenings will include a history and observations based on a health screening form. Id. The
screening form supplied by the State is adequate, but will require some progress notes to be
attached and cross-referenced in the case of positive answers to questions that require follow-up.
B.

Baylor
1.

Findings

As a preliminary matter, the Monitoring Team was unable in some instances to
measure the timeliness of the receiving screening because the correctional officers did not
consistently document the date and time of the inmate’s arrival at Baylor. At Baylor, for each
medical reception chart the Monitoring Team reviewed, there was a handwritten booking form
completed by the correctional officer. The Monitoring Team found that these forms did not
consistently document the date and time of the inmate’s arrival. The State has informed the
Monitoring Team that this information is documented elsewhere. The Monitoring Team will
follow up on this item in future reports.
In those records that the Monitoring Team reviewed where timeliness was
measurable, the Monitoring Team found that 3 out of 10 records reflected that the nurses did not
complete the Intake Screening Report within the four-hour time frame.
With respect to the appropriateness of the receiving screening, progress notes, if
written, often were not referred to on the screening report form, which meant that such notes
would not be helpful. The Monitoring Team also observed that when inmates arrived who were
already on medication, the nurses were not consistently documenting the medication dosages.
2.

Assessment

33

The Monitoring Team found that Baylor is in partial compliance with this
provision of the MOA.
C.

DCC
1.

Findings

The Monitoring Team found that in nine out of ten records reviewed reflected that
the receiving screenings took place within four hours of the inmate arriving at DCC. With
regard to the adequacy of the receiving screenings, more than half of the receiving screenings
reviewed by the Monitoring Team either were incomplete or not adequately performed. The
most common problem that the Monitoring Team found was that the person conducting the
receiving screening did not include sufficient follow-up details when an inmate answered “yes”
to questions that require further information from the inmate.
With regard to intrasystem transfers, the Monitoring Team found that five out of
ten of the records reviewed demonstrated some deficiencies concerning the follow-up or
continuity of care afforded to the inmate.
2.

Assessment

The Monitoring Team found that DCC is in partial compliance with this provision
of the MOA.
D.

HRYCI
1.

Findings

The Monitoring Team selected 20 records for review. These records represented
a sample of those inmates who had entered HRYCI within the previous three weeks.
The Monitoring Team found that 55% of the records reviewed demonstrated that
the inmate had a tuberculosis (“TB”) test planted and read within the first four days of arrival at
HRYCI. The Monitoring Team found that, in almost all cases the TB test was planted. There
were instances in which there was no documentation of the TB test in the chart, but those
instances were the exception.
With regard to the adequacy of the receiving screenings at HRYCI, the
Monitoring Team found that, similar to the findings at DCC, most of the receiving screenings
records reviewed did not include sufficient follow-up details when an inmate answered “yes” to
questions that require further information from the inmate.
2.

Assessment

The Monitoring Team found that HRYCI is in partial compliance with this
provision of the MOA.

34

E.

SCI
1.

Findings

The Monitoring Team selected 20 charts to review at SCI for this provision of the
MOA. Although the Monitoring Team noted that screening had been completed, the Monitoring
Team was unable to assess the timeliness of the receiving screenings at SCI because of a lack of
documentation of the inmate’s time of arrival at the Facility. With regard to the adequacy of the
receiving screenings at SCI, the Monitoring Team found that, like DCC and HRYCI, a number
of the receiving screening records reviewed did not include sufficient follow-up details when an
inmate answered “yes” to questions that require further information from the inmate.
2.

Assessment

The Monitoring Team found that SCI is in partial compliance with this provision
of the MOA.
F.

Recommendation

The Monitoring Team recognizes that the implementation of the new DACS
might have a considerable positive impact on the State’s compliance with the provisions of the
MOA. The Monitoring Team recommends that the State take the following actions at Baylor
and SCI: (i) draft and implement procedures that ensure that all screening is performed timely
and completely; and (ii) begin self-monitoring of implementation.
11.

Privacy
A.

Relevant MOA Provision
Paragraph 11 of the MOA provides:
The State shall make reasonable efforts to ensure inmate privacy when
conducting medical and mental health screening, assessments, and
treatment. However, maintaining inmate privacy shall be subject to
legitimate security concerns and emergency situations.

The MOA requires that the State make “reasonable efforts” to ensure inmate
privacy when conducting medical and mental health screening, assessments, and treatment,
subject to legitimate security concerns and emergency situations. This provision of the MOA
differs somewhat from the NCCHC standards, which provide for clinical encounters43 to be
conducted in private, without being observed or overheard by security personnel unless the
43

“Clinical encounters” are defined as “interactions between inmates and health care providers
that involve a treatment and/or an exchange of confidential information.” J-A-09; P-A-09.

35

patient poses a probable risk to the safety of the health care provider or others. J-A-09; P-A09.44 The MOA does not require an individual correctional officer to make an independent
assessment of the security risk of an individual inmate. Rather, the State can set the procedures
for correctional officers to follow to ensure that privacy is afforded in accordance with this
provision of the MOA.
The policies adopted by the State call for healthcare to be provided with
consideration of inmate dignity and feelings. See State Policy A-09. Further, healthcare
encounters are to be carried out in a manner and location that promotes confidentiality within the
dictates of security and safety. Id. The State’s policy calls for security staff or interpreters who
may be present during healthcare encounters to be informed and educated regarding the need for
confidentiality. Id. Finally, the State’s policy provides for a female escort to be provided for
encounters with a female inmate by a male healthcare provider. Id.
B.

Baylor
1.

Findings

Due to the lack of sufficient clinic examination rooms, the nurses conduct sick
call in the infirmary hallway where there is no auditory or visual privacy. In addition, because
there is no correctional officer posted in the infirmary, inmates are free to wander about the
clinic and overhear conversations or view confidential health documents laying on desks in the
hallway. The Monitoring Team learned that Baylor has formed a plan to use the infirmary space
in a more efficient manner, which promotes greater patient privacy.
The Monitoring Team also found that, with respect to the provision of mental
health services, there is no office designated for private contacts by mental health staff for
women on close observation. The mental health staff interviews women in the dental office if it
is not in use. Otherwise, there is no private area to assess the inmate. Also, women who are on
suicide precautions should be allowed a privacy curtain to use the toilet, if it is clinically
appropriate (see infra.) for such a curtain to be in the observation room.
2.

Assessment

The Monitoring Team found that Baylor is not in compliance with this provision
of the MOA. At the time of the Monitoring Team’s visit, it appeared that the State was not
44

Further, NCCHC standards provide that, in cases in which it is necessary for security
personnel to overhear clinical encounters, security personnel should be instructed regarding the
maintenance of confidentiality of health information. Id. Such privacy is not feasible under all
circumstances, such as instances in which health staff is dealing with an inmate’s health concern
at the inmate’s cell, or in Facilities in which space issues do not allow for privacy as described
above. Under such circumstances, if safety is a concern and full visual privacy cannot be
afforded, the NCCHC recommends that alternative strategies for partial privacy, such as a
privacy screen, be used. Id.

36

making reasonable efforts to ensure patient privacy. The State has informed the Monitoring
Team that there are concrete plans to improve patient privacy issues. These efforts will be the
subject of future reports.
C.

DCC
1.

Findings

The Monitoring Team observed that the infirmary unit does not have an
examination room. As a result, examinations are performed in the patient rooms, even when
those rooms are occupied by multiple inmates in a dormitory style. In some of the patient rooms,
the beds are so close together that it is not possible to obtain visual or aural privacy. If DCC is
unable to create a space for an infirmary examination room to afford inmate’s greater privacy,
the State should, at the very least, provide for some means of dividing inmate rooms so that at
least visual privacy can be maintained for examinations.
With regard to the privacy of mental health services, the Monitoring Team found
that there is one office available for every tier (four per 100 inmates), and one group space. This
office space is adequate to afford reasonable privacy. The Monitoring Team found one problem
regarding the privacy afforded by the office space, which is that mental health professionals do
not have the option to close the doors during interviews with inmates because the office doors
lock automatically upon closing.
Space within the infirmary for the provision of mental health services is not
adequate. The State is making reasonable efforts, however, to remedy this situation
2.

Assessment

The Monitoring Team found that DCC is in partial compliance with this provision
of the MOA.
D.

HRYCI
1.

Findings

The Monitoring Team found that all clinical encounters are conducted with doors
open and correctional officers standing in the doorway, regardless of the need to do so.45
The Monitoring Team also observed that the room used for chronic clinics is
typically so hot that the door is left open. The problem with that situation is that the chronic
45

By way of example, during a visit by the Monitoring Team, one of the medical experts
requested to meet in private with an inmate. The correctional officer refused the expert’s
request, stating, “This is a prison. There is no privacy in a prison.” The State has informed the
Monitoring Team that the correctional officer’s conduct is not representative of the State’s
approach to inmate privacy, and that the correctional officer has been disciplined.
37

clinic room is adjacent to the waiting room, and therefore, inmates and correctional officers are
immediately outside of the door and can overhear the clinical encounters taking place.
The Monitoring Team also observed a nursing station that is being shared with
security personnel. This shared space jeopardizes the confidentiality of inmate medical records.
2.

Assessment

The Monitoring Team found that HRYCI is not in compliance with this provision
of the MOA with regard to the privacy afforded to inmates receiving medical services, and is in
partial compliance with regard to the privacy afforded to inmates receiving mental health
services.
E.

SCI
1.

Findings

The Monitoring Team found that some of the housing units provide no private or
confidential space for clinical encounters, and most clinical encounters occur in public. This is a
serious concern with regard to the ability of staff to adequately assess an inmate’s suicide risk.
2.

Assessment

The Monitoring Team found that SCI is not in compliance with this provision of
the MOA. At the time of the Monitoring Team’s visit, it appeared that the State was not making
reasonable efforts to ensure patient privacy. The State has informed the Monitoring Team that
there are concrete plans to improve patient privacy issues. These efforts will be the subject of
future reports.
F.

Recommendation

The Monitoring Team recommends that the State create a plan that ensures
professional and adequate assessment space while also ensuring security at Baylor.
The Monitoring Team recommends that the State develop and implement
procedures that ensure professionally appropriate assessment space at DCC.
The Monitoring Team recommends that the State create a plan that provides for
confidential assessment space in both the clinic and inpatient areas at HRYCI.
The Monitoring Team recommends that the State create a plan to the Monitor that
ensures a professionally appropriate environment for all encounters at SCI.
12.

Health Assessments
A.

Relevant MOA Provision
38

Paragraph 12 of the MOA provides:
The State shall ensure that all inmates receive timely medical and mental
health assessments. Upon intake, the State shall ensure that a medical
professional identifies those persons who have chronic illness. Those
persons with chronic illness shall receive a full health assessment between
one (1) and seven (7) days of intake, depending on their physical
condition. Persons without chronic illness should receive full health
assessment within fourteen (14) days of intake. The State will ensure that
inmates with chronic illnesses will be tracked in a standardized fashion. A
readmitted inmate or an inmate transferred from another facility who has
received a documented full health assessment within the previous twelve
(12) months, and whose receiving screening shows no change in health
status, need not receive a new full medical and mental health assessment.
For such inmates, medical staff and mental health professionals shall
review prior records and update tests and examinations as needed.
The MOA provides for timely and adequate medical and mental health
assessments to occur. NCCHC standards differ with respect to timeliness of a health
assessment (compare J-E-04 and P-E-04 (stating that health assessments in jails take place “[a]s
soon as possible, but no later than 14 days…” and in prisons, “[a]s soon as possible, but no later
than 7 days…”)), but the MOA requires that the State adhere to the standard for jails, which is 14
days.47 An adequate health assessment should include at least:
46

•

a review of receiving screening results;

•

the collection of additional data to complete the medical, dental, and
mental health histories;

•

a recording of vital signs;

•

a physical examination (an objective, hands-on evaluation of an
individual, involving the inspection, palpation, auscultation, and
percussion of a patient’s body to determine the presence or absence of
physical signs of disease);

•

laboratory and/or diagnostic tests for communicable diseases including
sexually transmitted diseases;

46

A “health assessment” is defined as “the process whereby the health status of an individual is
evaluated, including questioning the patient regarding symptoms.” J-E-04; P-E-04.

47

The State’s policy adopts the 7-day standard applicable to prisons for timeliness of health
assessments. See State Policy E-04.

39

•

a test for TB; and

•

initiation of therapy and immunizations when appropriate.

Id. The hands-on portion of the health assessment should be performed by a physician,
physician assistant, or nurse practitioner, and the health history and vital signs should be
collected by a qualified health care professional.48 Id. When significant findings are present as
the result of the hands-on portion of the health assessment, and it is done by a health professional
other than a physician, the physician should document his or her review of the health
professional’s health assessment in the inmate’s medical record.
B.

Baylor
1.

Findings

After a review of medical records, the Monitoring Team found that inmates are
not consistently receiving physical examinations within the required time frames, and as
discussed in reference to paragraph 10 of the MOA, in two cases discovered by the Monitoring
Team, health assessments did not occur when warranted (e.g., when newly arrived inmates are
demonstrating symptoms of sexually transmitted diseases, which would warrant a health
assessment prior to the expiration of fourteen days). Furthermore, in three of ten records
reviewed, TB tests were not consistently documented.
2.

Assessment

The Monitoring Team found that Baylor is in partial compliance with this
provision of the MOA.
C.

DCC
1.

Findings

The Monitoring Team reviewed ten charts, and found that in some, the physical
examination was not completed. The Monitoring Team did not find a complete initial problem
list or plan in many of the records reviewed.
With respect to the mental health assessments, the Monitoring Team found that
mental health staff was not reviewing the files of inmates transferred to DCC from other
Facilities.

48

The hands-on portion of the health assessment may be performed by a registered nurse when
(i) the nurse completes appropriate training, approved or provided by the responsible physician;
and (ii) the responsible physician documents his or her review of all health assessments. J-E-04;
P-E-04.
40

2.

Assessment

The Monitoring Team found that DCC is in partial compliance with this provision
of the MOA.
D.

HRYCI
1.

Findings

The Monitoring Team found that half of the records reviewed did not reflect a
timely health assessment, and several records indicated that no health assessment had been
completed. The Monitoring Team found that, of those records that reflected completed health
assessments, appropriate referrals to chronic care program were made.
With respect to the mental health assessments, the Monitoring Team found that
mental health staff was not reviewing the files of inmates transferred to HRYCI from other
Facilities.
2.

Assessment

The Monitoring Team found that HRYCI is in partial compliance with this
provision of the MOA.
E.

SCI
1.

Findings

The Monitoring Team found that health assessments were completed in most of
the records reviewed; however, the health assessments were completed within the MOA’s 14day requirement.
The Monitoring Team found that mental health assessments are occurring in a
timely fashion. The Monitoring Team found that mental health assessments generally are
complete and appropriately refer individuals identified with mental health problems for further
review. The only exception found by the Monitoring Team was that one newly hired mental
health professional was completing the incorrect form for the health assessment, but that problem
has been remedied.
2.

Assessment

The Monitoring Team found that SCI is in partial compliance with this provision
of the MOA with regard to the medical health assessments performed on inmates, and in
substantial compliance with regard to the mental health assessments performed on inmates.
F.

Recommendation

41

The Monitoring Team recommends that the State: (i) draft and implement
procedures to ensure the timely and appropriate health assessments are completed within seven
days of entry; (ii) ensure that the assessments include an initial comprehensive problem list with
relevant diagnostic and therapeutic plans; and (iii) begin self-monitoring of timeliness,
appropriateness and completeness of health assessments.
13.

Referrals for Specialty Care
A.

Relevant MOA Provision
Paragraph 13 of the MOA provides:
The State shall ensure that: a) inmates whose serious medical or mental
health needs exceed the services available at their facility shall be referred
in a timely manner to appropriate medical or mental health care
professionals; b) the findings and recommendations of such professionals
are tracked and documented in inmates’ medical files; and c) treatment
recommendations are followed as clinically indicated.

The MOA requires that the State ensure that inmates whose medical or mental
health needs exceed the services available at the Facility shall be referred in a timely manner to
appropriate medical and mental health care professionals. For routine referrals, generally
accepted professional standards would permit a timely referral to be defined as being seen by a
specialist within 40 days, unless that inmate is seen by the primary care physician at the Facility
every 30 days until the specialist appointment occurs. In any event, the appointment with the
specialist should not occur more than 100 days after the initial request. For urgent consultations,
the process should occur within 14 days. In addition, the MOA requires that once an inmate has
seen the appropriate medical or mental health professional, the findings and recommendations
are tracked and documented in inmates’ files, and the patients are seen in follow-up by their
primary care physician at the Facility.
B.

Baylor
1.

Findings

The Monitoring Team reviewed several charts of patients for whom consultations
had been ordered. The Monitoring Team found that most of the medical consults are occurring
on a timely basis, but that there is a lack of consistency in reports being available on a timely
basis, follow-up visits occurring after an appointment, and documentation in the inmate’s
medical record regarding the reasons for the initial referral.
The problems identified by the Monitoring Team with Baylor’s compliance with
this provision of the MOA relate mainly to a lack of adequate administrative staff and resources
for the clinicians. The consult scheduler does not have a phone or computer at his/her desk. The
Health Services Administrator at Baylor has brought in her own laptop to assist with this process.
Tracking is done on paper, which is then later entered into the computer tracking system. The
physician maintains her own personal notebook tracking system to try to ensure that inmates are

42

receiving appropriate follow-up (e.g., discussions with patients) after consultations, but this
method does not always ensure that these visits occur as required.
2.

Assessment

The Monitoring Team found that Baylor is in partial compliance with this
provision of the MOA with respect to medical services. The Monitoring Team was unable to
assess Baylor’s compliance with this provision of the MOA in relation to mental health services,
as there had been no recent referrals offsite for mental health care at the time of the Monitoring
Team’s visit.
C.

DCC
1.

Findings

The Monitoring Team found that from June 2007 until the beginning of August
2007, specialty referrals were not occurring because the person who was assigned to schedule
appointments for inmates was on sick leave, and CMS had failed to find a temporary
replacement. The Monitoring Team learned that after the Monitoring Team’s visit, a new person
had been assigned to assist with the task of scheduling; however, that person was not at DCC
full-time, which resulted in additional delays in scheduling specialty appointments. After
reviewing patients referred by a primary care physician from the beginning of August, the
Monitoring team found that there were a total of 94 referrals generated in which there had been
an authorization from CMS’s central office for the service to be provided to an inmate.49
However, at the time the Monitoring Team reviewed these records, no phone call had been made
to schedule those inmate’s appointment.
With respect to the process for ensuring that that the findings and
recommendations of the specialty professionals are tracked and documented in inmates’ medical
files, and followed as clinically indicated, the Monitoring Team found that in half of the charts
reviewed, reports were missing and follow-up visits between the primary care physician at the
Facility and the inmate did not occur.

49

The process that is in place is supposed to include a referral from the primary care physician
along with an order and a progress note, which are then sent to the CMS central office. The
CMS central office reviews the referral and responds by either authorizing the referral or
recommending another strategy. The authorization is returned to the facility for scheduling to
take place with the outside provider, and the inmate ultimately should be taken to the
appointment.
The Monitoring Team found that referrals are typically received by the CMS central office
within one day, and that the CMS central office typically responds within one or two days. This
is satisfactory. Thus, the front end of the process is functioning. The problem lies in the delay in
making the telephone call to outside providers to schedule appointments.

43

2.

Assessment

The Monitoring Team found that DCC is in partial compliance with this provision
of the MOA.
D.

HRYCI
1.

Findings

The Monitoring Team reviewed charts of patients for whom consultations had
been ordered. The Monitoring Team found that all of the records reviewed had a timely referral
to specialty care and went to the appointment within the required timeframe. The Monitoring
Team found that in half of the records reviewed, physician follow-up did not occur.50 The
Monitoring Team also found that, in a couple of cases, the specialty referral was most likely not
necessary, and the unnecessary referral resulted from an inadequate physician assessment.
2.

Assessment

The Monitoring Team found that HRYCI is in partial compliance with this
provision of the MOA.
E.

SCI
1.

Findings

The records of approximately ten patients were reviewed and the Monitoring
Team found that, in most of the cases reviewed, the referral and specialty care appointment
occurred on a timely basis. The Monitoring Team found, however, that follow-up with a patient
after a specialty consultation did not occur on a consistent basis, and reports from specialty
consultations were not appearing in the file in a timely fashion.
2.

Assessment

The Monitoring Team found that SCI is in partial compliance with this provision
of the MOA.
F.

Recommendation

The Monitoring Team recommends that the State take the following actions at
Baylor and DCC: (i) draft and implement procedures to ensure timely scheduling of specialty

50

None of the specialty referrals reviewed at HRYCI were of an urgent nature. The Monitoring
Team observed that the tracking system used currently does not allow for reporting on urgent
requests.

44

services; and (ii) draft and implement procedures to ensure tracking and timely receipt and
follow-up of all reports.
The Monitoring Team recommends that the State take the following actions at
HRYCI: (i) implement procedures that ensure timely appointments, reports, follow-up visits and
responses to reports; and (ii) begin self-monitoring of timeliness of availability of appointments
deemed urgent and organize by specialty.
The Monitoring Team recommends that the State take the following actions at
SCI: (i) draft and implement procedures to ensure timely and appropriate specialty services,
including follow-up; and (ii) begin self-monitoring of compliance with Delaware Department of
Correction policy.
14.

Treatment or Accommodation Plans
A.

Relevant MOA Provision
Paragraph 14 of the MOA provides:
Inmates with special needs shall have special needs plans. For inmates
with special needs who have been at the facility for thirty (30) days, this
shall include appropriate discharge planning. The DOJ acknowledges that
for sentenced inmates with special needs, such discharge planning shall be
developed in relation to the anticipated date of release.51
A treatment plan for a special needs inmate should include, at a minimum:
•

the frequency of follow-up for medical evaluation and adjustment of the
treatment modality;

•

the type and frequency of diagnostic testing and therapeutic regimens; and

•

when appropriate, instructions about diet, exercise, adaptation to the
correctional environment, and medication.

J-G-01; P-G-01. Further, each Facility should maintain a list of special needs inmates for
tracking purposes. Id. With respect to discharge planning, in cases of a planned discharge, (i)
the health staff of a Facility should arrange for a sufficient supply of current medications to last
until the inmate can be seen by a community health care provider; and (ii) for inmates with

51

According to Section II.F. of the MOA, “inmates with special needs” are,
[I]nmates who are identified as suicidal, mentally ill, developmentally disabled,
seriously or chronically ill, who are physically disabled, who have trouble
performing activities of daily living, or who are a danger to themselves.
45

critical medical or mental health needs, arrangements or referrals should be made for follow-up
services with community providers. J-E-13; P-E-13.
B.

Baylor
1.

Findings

The Monitoring Team found that most of the medical files reviewed for mental
health treatment plans had treatment plans that included medication management, group therapy
(although that was not occurring), and independent journaling as the components of treatment.
In general, the treatment plans did not appear to be made specific enough to the needs of each
individual inmate. The Monitoring Team concluded that this lack of specificity might reflect the
absence of services beyond crisis, initial assessments, and well-being visits.
2.

Assessment

The Monitoring Team did not assess Baylor’s compliance with this provision of
the MOA as it relates to treatment plans and discharge planning for inmate with non-mental
health related special needs. The Monitoring Team found that Baylor is in partial compliance
with this provision of the MOA with respect to treatment plans and discharge planning for
inmates with special needs due to serious mental illness.
C.

DCC
1.

Findings

The Monitoring Team found that there is one discharge group for the entire
facility, and that every clinician is required to track those inmates leaving within 30 to 90 days.
The Monitoring Team was told that the elements of discharge planning are supposed to follow a
CMS form to make contact for outpatient appointments, assess housing needs, support, and
pharmacy information.
Upon review, the Monitoring Team found that CMS will make appointments for
inmates being discharged if the inmate identifies a community provider. The Monitoring Team
found that financial entitlements were expedited on only two occasions by filling out Medicaid
applications for inmates. The State is aware of the need to assist soon-to-be released inmates
with these applications, and is working to improve the process.
The Monitoring Team also found that referrals for the Delaware Psychiatric
Center are rarely necessary. When such referrals are necessary, however, a psychiatrist sees the
inmate and refers the inmate for involuntary admission.
The Monitoring found that distribution of medication to inmates being discharged
is problematic. The Monitoring Team learned from mental health staff leadership that inmates
being discharged are supposed to receive a 30-day supply of medication, that the nursing staff is
supposed to notify the booking area (i.e., the area from which inmates are discharged from the

46

Facility) when the medication is ready, and that the inmate is to receive the medication supply in
the booking area. The Monitoring Team learned from correctional officers that, in their
experience, it is rare for any inmate to be released with a supply of medication, but that if an
inmate notifies them that medication is necessary, the officers will contact the nursing staff for
the medication. This information was later verified, which means that medication is very rarely
provided to inmates upon release from the Facility.
2.

Assessment

The Monitoring Team deferred assessing DCC’s compliance with this provision
of the MOA as it relates to inmates that are regarded as special needs for reasons other than
serious mental illness because the State and the Monitoring Team were attempting to resolve
differing interpretations of the appropriate standards to apply in monitoring this provision of the
MOA. The State and the Monitoring Team were able to resolve the differing interpretations to
determine that special accommodation plans should be placed on the problem list in an inmate’s
medical record, and that the special accommodation plan should include an inmate’s diagnosis,
the date of the initial diagnosis in the DOC, a description of what special needs the inmate has
that cause the need for a special accommodation plan, the planned accommodation strategies,
and discharge planning prior to the patient’s release. Also, there should be an assessment of the
effectiveness of the accommodation plan within 30 days of development of the initial plan, and
then no less frequently than every 90 days thereafter, similar to the process that should be in
place for the chronic care program. The Monitoring Team will monitor the State’s compliance
with these requirements during the next period. .
The Monitoring Team found that the State is in partial compliance with this
provision of the MOA with respect to treatment and discharge plans for inmates whose serious
mental illness qualifies them as special needs inmates.
D.

HRYCI
1.

Findings

The Monitoring Team found that discharge plans for inmates often lack
individualization, and include little or no intervention relating to entitlements for inmates being
released. Discharge plans do, however, usually involve the following items: (i) a 30-day supply
of medication upon release; (ii) a timely appointment with a community health center near the
inmate’s home if the inmate has remained “substance free;” and (iii) if the inmate is incarcerated
for more than two years, the inmate is transferred to a step-down facility within the DOC where
CMS continues to care for the inmate.
2.

Assessment

The Monitoring Team did not assess HRYCI’s compliance with this provision of
the MOA as it relates to treatment plans and discharge planning for inmates with non-mental
health related special needs for the same reason as stated above with respect to DCC. The
Monitoring Team found that HRYCI is in partial compliance with this provision of the MOA

47

with respect to treatment plans and discharge planning for inmates with special needs due to
serious mental illness.
E.

SCI
1.

Findings

The Monitoring Team found that treatment plans are generated on each patient.
In addition, in one chart, the Monitoring Team found an excellent discharge plan. SCI earned a
partial compliance rating, however, because a rating of substantial compliance cannot be founded
on only one record. The Monitoring Team is hopeful that it will encounter additional discharge
plans of the caliber noted above upon its next visit to monitor this provision of the MOA.
2.

Assessment

The Monitoring Team did not assess SCI’s compliance with this provision of the
MOA as it relates to treatment plans and discharge planning for inmate with non-mental health
related special needs. The Monitoring Team found that SCI is in partial compliance with this
provision of the MOA with respect to treatment plans and discharge planning for inmates with
special needs due to serious mental illness.
F.

Recommendation
The Monitoring Team recommends that the State take the following action at

DCC:

15.

z

With detainees, discharge planning should be at the time of the initial visit. This
gathering of information should be done by the counselor at time of assessment
and treatment planning.

z

A system needs to be developed and implemented re: financial entitlements such
as Medicaid and social security benefits.

z

A QI needs to address discharge planning issues, especially discharge
medications.

Drug and Alcohol Withdrawal
A.

Relevant MOA Provision
Paragraph 15 of the MOA provides:
The State shall develop and implement appropriate written policies,
protocols, and practices, consistent with standards of appropriate medical
care, to identify, monitor, and treat inmates at risk for, or who are
experiencing, drug or alcohol withdrawal. The State shall implement

48

appropriate withdrawal and detoxification programs. Methadone
maintenance programs shall be offered for pregnant inmates who were
addicted to opiates and/or participating in a legitimate methadone
maintenance program when they entered the Facilities.
This provision of the MOA requires that the State develop and implement
appropriate written policies, protocols, and practices, consistent with standards of appropriate
medical care, to identify, monitor, and treat inmates at risk for, or who are experiencing, drug
and alcohol withdrawal. The State has developed an adequate policy with respect to drug and
alcohol withdrawal. See State Policy G-06.
Further, established protocols regarding the treatment and observation of
individuals manifesting symptoms of intoxication or withdrawal should be followed in order to
complete successful implementation of the policies. J-G-06; P-G-06. Inmates experiencing
severe, life-threatening intoxication (overdose) or withdrawal should be transferred immediately
to a licensed acute care facility. Id. Individuals at risk for progression to more severe levels of
intoxication withdrawal should be kept under constant observation by qualified health care
professionals or health-trained correctional staff, and whenever severe withdrawal symptoms are
observed, a physician should be consulted promptly. Id. If a pregnant inmate is admitted with a
history of opiate use, a physician should be contacted so that the opiate dependence can be
assessed and treated appropriately. Id. The facility should have a policy that addresses the
management of inmates, including pregnant inmates, on methadone or other similar substances.
Pregnant inmates entering the facility who were addicted to opiates and/or participating in a
legitimate methadone maintenance program should be offered methadone maintenance
programs.
B.

Baylor
1.

Findings

The Monitoring Team studied the treatment of the two inmates identified as
undergoing alcohol withdrawal. One of the patients’ charts had no evidence of nursing
evaluation, even though there was an order for the withdrawal protocol. The second patient’s
chart was incomplete. The Monitoring Team found that the patient had gone to the hospital and
was diagnosed with heroin and alcohol withdrawal. The chart was unclear as to how the patient
got to the hospital. At the time the patient came to the facility, the patient presented with a
history of pancreatitis, current abdominal pain, and nausea. Laboratory tests ordered for this
urgent presentation were not done for seven days after the patient returned from the hospital.
2.

Assessment

The Monitoring Team found that Baylor is not in compliance with this provision
of the MOA.
C.

DCC

49

The Monitoring Team did not assess DCC’s compliance with this provision of the
MOA because at the time the Monitoring Team visited the Facility to review this item, the
Monitoring Team had not received drafts of specific clinical guidelines for alcohol and opiate
withdrawal monitoring and treatment.
D.

HRYCI

The Monitoring Team did not assess HRYCI’s compliance with this provision of
the MOA. The Monitoring Team did make some preliminary observations, however. The
Monitoring Team observed that the withdrawal policy and procedures were performed by LPNs
without much supervision, and a nurse was permitted to initiate the protocol without a physician
conducting an initial evaluation. For one patient reviewed by the Monitoring Team, there were
no notes by the LPN, which made it difficult to determine the status of the patient, and gave the
appearance of unmonitored detoxification.
E.

SCI
1.

Findings

The Monitoring Team reviewed one record of a patient with withdrawal, and the
record demonstrated multiple serious problems. The inmate experienced severe symptoms of
alcohol withdrawal, did not receive appropriate withdrawal treatment, and was placed in
restraints without following clinically appropriate procedures. The DOC expressly informed the
Monitoring Team of this incident, acknowledged the deficiencies, and has been working to
improve the issues highlighted by the incident.
2.

Assessment

The Monitoring Team found that SCI is not in compliance with this provision of
the MOA.
F.

Recommendation

The Monitoring Team recommends that the State draft and implement the policies
and procedures required by this provision of the MOA, and provide training on those policies
and procedures.
16.

Pregnant Inmates
A.

Relevant MOA Provision
Paragraph 16 of the MOA provides:
[t]he State shall develop and implement appropriate written
policies and protocols for the treatment of pregnant inmates,
including appropriate screening, treatment, and management of
high risk pregnancies.”

50

According to NCCHC standards, pregnant inmates shall receive timely and
appropriate prenatal care, specialized obstetrical services when indicated, and postpartum care.
J-G-07. Appropriate prenatal care should include medical examinations, laboratory and
diagnostic tests (including offering HIV testing and prophylaxis when indicated), and advice on
appropriate levels of activity, safety precautions, and nutritional guidance and counseling. Id.
B.

Baylor
1.

Findings

In general, care of pregnant inmates is good. With regard to timeliness, the
Monitoring Team found that in about 80% of cases reviewed, pregnant inmates were seen on a
timely basis. Care of pregnant inmates is provided by a nurse practitioner who works for a local
obstetrician, and therefore, can hold clinic only one day per week. Thus, if an inmate arrives at
Baylor the day after clinic, she will not be seen until a week later.
The Monitoring Team observed several cases in which the prenatal care offered to
pregnant inmates was not adequate. In a couple of cases, the pregnant inmate was not seen for 3
or 4 weeks, when pregnant inmates should be seen within a few days of arrival or sooner if
clinically indicated. Also, most of the pregnant inmates received appropriate laboratory tests in a
timely manner. The Monitoring Team found that pregnant inmates with high risk pregnancies
have access to hospital care.
One problem noted by the Monitoring Team was that pregnant inmates nearing
labor or post-partum are housed in a room in the infirmary that is not within sight or sound of the
nursing staff, which is not an appropriate housing location. This problem could be remedied by
placing a camera and some sort of call button in that room.
2.

Assessment

The Monitoring Team found that Baylor is in partial compliance with this
provision of the MOA.
3.

Recommendation

The Monitoring Team recommends that the State create a plan to improve
timeliness of intake pregnancy assessments and a long-term plan for housing females who are
near labor or are post partum.
17.

Communicable and Infectious Disease Management
A.

Relevant MOA Provision
Paragraph 17 of the MOA provides:
The State shall adequately maintain statistical information
regarding contagious disease screening programs and other

51

relevant statistical data necessary to adequately identify, treat, and
control infectious diseases.
The NCCHC recommends that facilities with populations over 500 inmates
should have a committee to oversee infection control practices. P-B-01. The infection control
committee should consist of representation from the facility’s administration, the responsible
physician or designee, nursing and dental services, and other appropriate professional personnel
involved in sanitation or disease control. Id. Further, facilities should follow a TB control plan
that is consistent with current published guidelines from the Centers for Disease Control.
B.

Baylor
1.

Findings

At the time the Monitoring Team visited Baylor to monitor this provision of the
MOA, the infection control nurse had been in that position for six months, and spent 80% of her
time in infection control. The infection control nurse did not have any computer or internet
access. The infection control nurse should undergo training in infection control so that
appropriate information is tracked and reported on to the Quality Improvement Committee on a
quarterly basis.
Formal processes for tracking important diseases such as TB and MRSA52 were
not in place. Although TB skin test information is maintained in the intake log book, the
information is not used to track prevalence data. In the future, TB data should include the total
number of TB tests, the number of previously positive inmates, the number of new positives, the
results of any follow-up chest films that are taken as the result of positive TB tests, and the
numbers of TB positive inmates who start and complete prophylactic therapy. Further, all active
cases should be tracked. All inmates who are skin test negative should have an annual skin test,
and the number of tests performed and the conversions from prior negative results to positive
results in a new test should be tracked. Any conversions from prior negative skin test to a
positive skin test should be investigated. In addition, all employee TB skin test data should be
tracked.
MRSA also should be tracked, and the tracked data should include the date and
housing location. Baylor has a MRSA tracking book, but at the time of the Monitoring Team’s
visit, the MRSA book was missing or lost, and had been reconstructed recently with two months’
worth of data. The tracking book did not contain any entries for October 2007, although there
was a woman in the infirmary for an extended period of time. She had had a MRSA wound
weeks prior that was not documented, and staff informed the Monitoring Team that they
estimated seeing about one MRSA case per month.
Hepatitis C is tracked on a log if the positive inmate is going to remain
incarcerated for more than 18 months. HIV results are obtained from the state laboratory and
positive patients are maintained on a log. HIV patients are not reported consistently. The
52

“MRSA” is the commonly known term for methicillin-resistant staphylococcus aureus, which
is a type of bacteria that is resistant to certain antibiotics.
52

infection control nurse was not reporting people whom she thought had been previously positive.
All HIV patients new to the facility should be reported to the State, even if there is redundancy.
Chlamydia and gonorrhea testing is done for all women who consent to a Pap smear. A list of
positives are maintained but prevalence data is not maintained. Infection control rounds are not
currently done. OSHA training is not recorded. Needle stick injuries are tracked by the Health
Service Administrator.
2.

Assessment

The Monitoring Team found that Baylor is in partial compliance with this
provision of the MOA.
C.

DCC
The Monitoring Team did not assess DCC’s compliance with this provision of the

MOA.
D.

HRYCI

The Monitoring Team did not assess HRYCI’s compliance with this provision of
the MOA. At the time of the Monitoring Team’s visit to HRYCI to monitor this provision, the
policy regarding communicable and infectious disease tracking was being modified.
E.

SCI
1.

Findings

The Monitoring Team found that an infection control nurse has been assigned at
SCI, but she is only able to devote five days per month to this work. The infection control nurse
was not trained with regard to conducting appropriate infection control rounds, or how to collect
and track data. SCI does not have an infection control report, and there are no infection control
meetings. SCI does not maintain TB prevalence data. At the time of the Monitoring Team’s
visit, the infection control nurse reported that from a review of 383 inmates’ medical records,
none of these individuals tested had a positive TB test, and the last positive skin test for TB
occurred several months prior to the Monitoring Team’s visit. That report should be investigated
further. In a high risk population such as in a correctional facility, it is highly unlikely that there
are no positive TB tests. If the data presented by the nurse is accurate, then it signifies that there
may be improper techniques being employed in implanting TB tests or reading the tests. SCI has
a MRSA log, but it only tracks positive skin cultures. SCI tracks vaccinations, which assists in
adequately preventing infectious diseases.
2.

Assessment

The Monitoring Team found that SCI is not in compliance with this provision of
the MOA.

53

F.

Recommendation

The Monitoring Team recommends that the State take the following action at
Baylor and SCI: (i) implement policies and procedures to ensure comprehensive automated
reporting and tracking of common diseases is implemented and used to monitor and reduce
liability; and (ii) submit infection control plan to the Monitor, including duties of the Infection
Control Nurse, along with training to be provided for these duties.
18.

Clinic Space and Equipment
A.

Relevant MOA Provision
Paragraph 18 of the MOA provides:
The State shall ensure that all face-to-face nursing and physician
examinations occur in settings that provide appropriate privacy and permit
a proper clinical evaluation including an adequately-sized examination
room that contains an examination table, an operable sink for handwashing, adequate lighting, and adequate equipment, including an
adequate microscope for diagnostic evaluations. The State shall submit a
comprehensive action plan as described in Paragraph 65 of [the MOA]
identifying the specific measures the State intends to take in order to bring
the Facilities into compliance with this paragraph.

An adequately-sized examination room is one that is large enough to
accommodate the necessary equipment, supplies, and fixtures, and to permit privacy during
clinical encounters. J-D-03; P-D-03. Facilities should have, at a minimum, the following
equipment, supplies, and materials for the examination and treatment of patients:
•

hand-washing facilities or appropriate alternate means of hand
sanitization;

•

examination tables;

•

a light capable of providing direct illumination;

•

scales;

•

thermometers;

•

blood pressure monitoring equipment;

•

stethoscope;

•

ophthalmoscope;

54

•

otoscope;

•

transportation equipment (e.g. wheelchair, stretcher);

•

trash containers for biohazardous materials and sharps; and

•

equipment and supplies for pelvic examinations if female inmates are
housed in the facility.

Id.
B.

Baylor
1.

Findings

Overall, the Monitoring Team found that space is inadequate at Baylor. The
space in the infirmary is too narrow and small to allow for adequate space to support staff
functions. For a discussion of how the lack of space impacts privacy of clinical encounters, see
the discussion above in relation to provision 11 of the MOA.
With regard to the impact of the clinic space on clinical examination and available
equipment, the Monitoring Team found that the spaces in the infirmary at Baylor are not wellorganized, and the sanitation is poor.53 For instance, in the examination room that appears to be
an optometry room, there are exposed pipes and valves of some sort, and the room contained a
cot and a toilet to be used by an inmate patient. The optometry equipment is broken, and when
the optometrist needs to perform a retina evaluation, he must go to the physician room to use the
ophthalmoscope.
The mental health staff sees patients in the dental office when the dentist is not
working. The infirmary has a single room for mental health observation, which has a single solid
shelf used as a bed. The Monitoring Team was informed that as many as four acute mental
health patients were kept in this room at one time.
2.

Assessment

The Monitoring Team found that Baylor is not in compliance with this provision
of the MOA.
C.

DCC
1.

Findings

53

Sanitation is a reflection both of disinfection and neatness. In order for the Monitoring Team
to determine that a space is sanitary, records or schedules of disinfection being performed need
to be available.
55

The Monitoring Team observed the clinic space, satellite clinic rooms, and the
infirmary unit in order to assess this provision of the MOA at DCC. In the clinic and satellite
clinic rooms, the Monitoring Team found that there was no functioning otoscope, which is used
to examine the ears, eyes, nose, and throat. Further, there was no sanitation and infection control
schedule to list the types and frequency of activities to maintain a clean and safe environment.
As a result, these rooms were not uniformly clean or adequately equipped or supplied. As an
example, the Monitoring Team found the segregation unit satellite medical clinic floors to be
dirty.
The infirmary space is inadequate. The lack of space affects clinical care,
privacy, sanitation and hygiene, medication management, and staff’s ability to perform
administrative functions. In addition, the Monitoring Team found that certain equipment is
either broken or not readily available. Examples of the lack of space and lack of certain
equipment are as follows:
•

There is capacity for 44 beds in the infirmary unit. Of these 44 beds, 21
are dormitory style. This affects the privacy that can be afforded to
inmates because it is virtually impossible not to have other inmates
overhear and/or see clinical encounters. Also, due to the crowding of the
infirmary cells, it is difficult for inmates using wheelchairs to maneuver in
these spaces.

•

At the time of the Monitoring Team’s visit, there was a broken Hoyer lift
in the infirmary unit.54 The broken Hoyer lift is partially dissembled in the
shower area, and the tub in the infirmary unit is not used in part because
patients who would benefit from using a tub instead of a shower are too
heavy and cannot be lifted into it.

•

On one day that the Monitoring Team visited the infirmary unit at DCC,
an ear examination could not be performed because there was not a
functioning otoophthalmoscope on the unit.

•

Also during a Monitoring Team visit, the Monitoring Team found that
because there is so little storage space, boxes of material and supplies are
kept in scattered locations of the floor even when they should be stored on
shelves. The store room was not orderly or clean.

•

There is no ice machine, so a cooler is kept on the counter near the only
sink in the infirmary unit, making it difficult to use the sink. It is also
problematic that there is only one sink for this unit.

•

The medication room is not large enough (about 40 square feet) given the
number of drugs which are required to be kept in stock.

54

A Hoyer lift is used to life incapacitated patients off of beds and onto a transfer device so that
nurses can move the patient to a shower and clean the bed.
56

•

The staff work space is approximately 80 square feet and is used by
clinical staff to write notes, review records, write consultations, make
phone calls and perform other charting.

2.

Assessment

The Monitoring Team found that DCC is in partial compliance with this provision
of the MOA. The Monitoring Team noted that the conditions at DCC are better than at the other
facilities and assigned the partial compliance rating as a result. However, the conditions at DCC
do not meet standards and the State has to demonstrate substantial improvement in order to
obtain a substantial compliance rating.
D.

HRYCI
1.

Findings

The areas assessed were the HRYCI infirmary (including the TB isolation room),
the chronic clinic room, the main clinic, and the East Side clinic. The Monitoring Team found
that all of these spaces are inadequate in size to allow staff to deliver clinically appropriate care.
Sanitation is still a problem, although improvement has been made.
Additionally, the air conditioning unit in the infirmary was not functioning
properly, leading to temperatures around 100 degrees Fahrenheit at times. The TB isolation
room does not deliver negative air pressure when the air conditioning is on. High temperatures
in the chronic care room have led to the door being kept open. The door opens into the waiting
room, and it being left open causes privacy concerns, as well as difficulty in providing services
due to noise from the waiting room. Likewise, the inadequacy of the clinic size also causes
privacy concerns as doors are kept open and guards stand in doorways when patients are being
examined.
2.

Assessment

The Monitoring Team found that HRYCI is not in compliance with this provision
of the MOA.
E.

SCI
1.

Findings

The Monitoring Team reviewed the intake screening area, the main clinic, and the
infirmary. The intake screening area is adequate. The other areas do not allow staff to deliver
clinically appropriate care.
The infirmary consists of several rooms along a common hall. One room has
three beds in it. All types of patients are mixed in this single room. The Monitoring Team was

57

informed that, at times, a psychotic person might be housed with an acutely ill patient. The
Monitoring Team also learned that the prior week, a person in alcohol withdrawal was in the
room with an ill person, and correctional officers had to intervene to remove one of the patients
on the basis of a security concern for the ill patient.
The Monitoring Team has several concerns about the lack of privacy provided in
these treatment areas. Nurses perform sick call in an open area without privacy. Treatments are
also performed in an open space. The infirmary consists of several rooms along a common hall.
The office where the doctor sees patients has the only staff restroom. As a result, people walk
through this office to use the restroom while the doctor is seeing patients. Finally, in the intake
screening area, medical records are not locked up but instead are available to any person walking
through the area.
The Monitoring Team has learned that the State has plans to remediate the
problems with infirmary space at SCI, which will be executed in the coming year. This item will
be the subject of further review by the Monitoring Team.
2.

Assessment

The Monitoring Team found that SCI is not in compliance with this provision of
the MOA.
F.

Recommendation

The Monitoring Team recommends that the State take the following actions with
respect to Baylor: create a plan to ensure that professional and appropriate space is used for
assessments and that patients’ housing and equipment needs are met.
The Monitoring Team recommends that the State take the following action with
respect to the DCC: (i) create a plan to address clinic area deficiencies; and (ii) create a plan to
address infirmary area deficiencies.
The Monitoring Team recommends that the State take the following action at SCI:
Create a plan that addresses the issues cited in the Findings. This plan may include short-term
and long-term strategies.

58

ACCESS TO CARE
19.

Access to Medical and Mental Health Services
A.

Relevant MOA Provision
Paragraph 19 of the MOA provides:
The State shall ensure that all inmates have adequate opportunity to
request and receive medical and mental health care. Appropriate medical
staff shall screen all written requests for medical and/or mental health care
within twenty-four (24) hours of submission, and see patients within the
next 72 hours, or sooner if medically appropriate. The State shall maintain
sufficient security staff to ensure that inmates requiring treatment are
escorted in a timely manner to treatment areas. The State shall develop
and implement a sick call policy and procedure which includes an
explanation of the order in which to schedule patients, a procedure for
scheduling patients, where patients should be treated, the requirements for
clinical evaluations, and the maintenance of a sick call log. Treatment of
inmates in response to a sick call slip should occur in a clinical setting.

NCCHC standards generally recommend that inmates have access to care to meet
their serious medical, dental, and mental health needs, and that unreasonable barriers to inmates’
access to health services are to be avoided.55
J-E-01; P-E-01. The MOA provides the
requirements for the Facilities’ sick call process, which is a large part of affording inmates access
to care. The MOA requires that appropriate medical staff screen56 all written requests for
medical and/or mental health care within 24 hours of submission, and see patients within the next
72 hours, or sooner if medically appropriate. Further, the MOA sets forth the required elements
of the State’s policies and procedures relating to the sick call process. Those elements are: (i) an
explanation of the order in which to schedule patients, (ii) a procedure for scheduling patients,
(iii) where patients should be treated, (iv) the requirements for clinical evaluations; and (v) the
maintenance of a sick call log. With respect to patient scheduling, not every sick call slip
requires an appointment; however, when a sick call slip describes a clinical symptom, a face-toface encounter between the inmate and a health professional is required. J-E-07; P-E-07. The

55

“Access to care” means that in a timely manner, a patient can be seen by a clinician, be given a
professional clinical judgment, and receive care that is ordered. J-E-01; P-E-01. The NCCHC
provides the following examples of unreasonable barriers to inmate health care: (i) punishing
inmates for seeking care for their serious health needs; (ii) assessing excessive co-pays; and (iii)
deterring inmates from seeking care for their serious health needs, such as by holding sick call at
2:00 a.m., when the practice is not reasonably related to the needs of the institution. Id.

56

The process of screening the written requests for medical or mental health care is referred to as
“triage.” The NCCHC defines “triage” as “the sorting and classifying of inmates’ health
requests to determine priority of need and the proper place for health care to be rendered.” J-E07; P-E-07.
59

sick call encounters should take place in a clinical setting (i.e., an examination or treatment room
appropriately supplied and equipped to address the patient’s health care needs). Id.
B.

Baylor
1.

Findings

There is a lack of a sufficient number of clean, well-equipped and supplied
examination rooms that afford privacy to detainees and inmates. This issue presents an
unreasonable barrier to an inmate accessing care in that it compromises confidentiality.
The Monitoring Team also found that nurses do not consistently see patients
within 72 hours of receiving their health service requests. In fact, sometimes patients are not
seen at all.
2.

Assessment

The Monitoring Team found that Baylor is not in compliance with this provision
of the MOA.
C.

DCC
1.

Findings

The Monitoring Team found that sick call slips were not being collected on a
timely basis, and consequently, inmates were not receiving timely access to care. In order to
come to this conclusion, the Monitoring Team reviewed sick call collection logs for September,
2007, which showed that sick call slips from certain housing units (S, E, V, T1 and T2) were not
collected on 13 of 30 days. Also, sick call slips from other housing units (C, DW, DE, and W)
were not collected on 18 of the 30 days. The Monitoring Team was unable to determine whether
staff simply did not complete the collection log on those days that did not demonstrate sick call
slip pickup, or whether the sick call slips in fact were not picked up on those dates. Staff
informed the Monitoring Team that the problems with collection of sick call slips were the result
of staff turnover in the employees assigned the task of picking up sick call slips.
It was difficult to assess the timeliness of care provided in response to sick call
slips, as the Monitoring Team found that staff was not time stamping the sick call requests until
they had been triaged (instead of the time of receipt), which could be several days after the initial
receipt of the sick call request. Staff also are not consistently signing and dating the triaged sick
call slips, often signing them with only the word “medical.” Further, the Monitoring Team
reviewed the sick call slips being reviewed at DCC on October 3, 2007. Those slips contained
forms collected on October 1 and 2, and many of the slips were dated September 25, 26, and 27.

60

The process is supposed to include the sick call slips being collected in the evening and triaged
the following morning.57
The Monitoring Team found that there is an additional delay in inmates being
seen by a nurse or clinician within 72 hours of receipt of the sick call slip. Following nursing
triage, patients are not immediately placed on the schedule, but are put onto a list of “to be
scheduled” inmates. This list appears to have become the practice because there are only so
many time slots per day in the schedule, and if the number of patients to be scheduled exceeds
the number of slots for the day, the inmate’s name is put on the next open date. As a result of
this process, however, some inmates were not seen for five to twelve days after nurse triage, and
often not seen at all.
In addition, in the records reviewed, the Monitoring Team found that the care
being provided in response to sick call slips was not adequate. Specifically, the quality of the
histories taken and physical examinations performed is poor, nursing diagnoses are not
appropriate, and the plan of care for the patient is not adequate.
Seven of the eight records reviewed showed that the patient was not evaluated in a
timely manner or at all. Additionally, nursing assessments were inadequate and physician
referrals did not consistently occur. Finally, the appointment scheduling system was
dysfunctional and contributed to further delays in access to care.
The Monitoring Team believes that the Assistant Director of Nurses, who had
then been at the facility for only two weeks, was taking a proactive approach to attempt to
correct the above-mentioned problems.
2.

Assessment

The Monitoring Team found that DCC is not in compliance with this provision of
the MOA.
D.

HRYCI
1.

Findings

The Monitoring Team monitored the sick call process at HRYCI twice to monitor
this provision of the MOA. During the first visit, the Monitoring Team found that, particularly
on the west wing of HRYCI, sick call slips were not consistently picked up on a daily basis,
meaning that timely access to care was not occurring. Further, the Monitoring Team found that
sick call slips were not being maintained in one place, and some had not been addressed at all
even though they extended back over several weeks.

57

The Monitoring Team also observed that some of the sick call slips indicated that they were
the third, fourth, or fifth request for the same issue.
61

The Monitoring Team then reviewed a limited sample of records of patients who
had been seen by the nurse practitioner. The records revealed that the nurse practitioner needs
closer supervision from the physician, as there were quality issues with each of the assessments
reviewed. Specifically, in reviewing sick call requests, the Monitoring Team found abnormal
vital signs that were not noticed or identified and also found inadequate physical assessments and
inadequate history taking in some instances.
During the Monitoring Team’s second visit to review the sick call process, the
Monitoring Team found that significant improvements have been made to the sick call
examination room. The room had been cleared out, and an examination table had been added.
The Monitoring Team was able to determine that sick call slips were being picked up daily from
Monday through Friday, but not on the weekends. Sick call slips should be picked up each day.
2.

Assessment

The Monitoring Team found that HRYCI is in partial compliance with this
provision of the MOA because the State has taken measures that have resulted in some
improvement to the sick call process at HRYCI.
E.

SCI
1.

Findings

The Monitoring Team found that nursing sick call assessments are being
performed by LPNs, and a review of those assessments reflected an inconsistent understanding
by the LPN’s of how to use the assessment form. Although LPNs are permitted to collect data to
assist with assessments, integrating the data and clinical decision-making should be left to RNs.
2.

Assessment

The Monitoring Team found that SCI is in partial compliance with this provision
of the MOA.
F.

Recommendation

At DCC, the Monitoring Team recommends that the State: (i) draft and
implement procedures to ensure that daily collection of sick call slips is documented and patients
with symptoms are seen in face-to-face assessments within one business day of paper triage; (ii)
draft and implement procedures that ensure that patients with symptoms that appear urgent are
seen within one shift of paper triage; (iii) the vendor should ensure that only RNs whose
competency has been validated perform sick call assessments; (iv) the vendor should ensure that
clinical performance review with feedback is provided timely and documented for all nurses
performing assessments; and (v) create a plan in which positive screens result in a timely mental
health assessment.

62

At HRYCI, the Monitoring Team recommends that the State: (i) implement a
process that ensures seven days-per-week pick up of health services requests for all units, timely
and appropriate triage of the requests and face-to-face assessments; and (ii) monitor its
compliance with this policy. Also, the Monitoring Team recommends that the screening process
needs to be further studied and revised so that only appropriate referrals are made and that all
inmates referred are seen on a timely.
At SCI, the Monitoring Team recommends that the State: (i) implement a plan to
utilize registered nurses to perform nursing assessments; and (ii) self-monitor for timeliness and
appropriateness of the assessments.
20.

Isolation Rounds
A.

Relevant MOA Provision
Paragraph 20 of the MOA provides:
The State shall ensure that medical staff58 make daily sick call rounds in
the isolation areas, and that nursing staff59 make rounds at least three times
a week, to give inmates in isolation60 adequate opportunities to contact and
discuss health and mental health concerns with medical staff and mental
health professionals61 in a setting that affords as much privacy as security
will allow.

58

According to the MOA, the term “medical staff” includes “medical professionals, nursing
staff, and certified medical assistants.” See MOA II.I. The term “medical professionals”
includes “a licensed physician, licensed physician’s assistant, or a licensed nurse practitioner
provision services at a facility and currently licensed to the extent required by the State of
Delaware to deliver those health services he or she has undertaken to provide” See MOA II.J.

59

According to the MOA, “Nursing Staff” means “registered nurses, licensed practical nurses,
and licensed vocational nurses providing services at a facility and currently licensed to the extent
required by the State of Delaware to deliver those health services he or she has undertaken to
provide.” See MOA II.M.

60

According to the MOA, “isolation” means “the placement of an individual alone in a locked
room or cell, except that it does not refer to adults single celled in general population.” See
MOA II.G.
61

“Mental Health Professionals” means “an individual with a minimum of a master’s-level
education and training in psychiatry, psychology, counseling, psychiatric social work, activity
therapy, recreational therapy or psychiatric nursing, currently licensed to the extent required by
the State of Delaware to deliver those mental health services he or she has undertaken to
provide.” See MOA II.K.

63

The purpose of this MOA provision is to ensure that inmates placed in isolation
maintain their medical and mental health while physically and socially isolated from the rest of
the inmate population. J-E-09; P-E-09. The NCCHC recommends that, upon notification that an
inmate is placed in segregation,62 a qualified health care professional reviews the inmate’s health
record to determine whether existing medical, dental, or mental health needs contraindicate the
placement or require accommodation, and that such an evaluation should be placed in the
inmate’s medical record. Id.
The Monitoring Team has identified some confusion over the proper
interpretation of this provision of the MOA. The NCCHC standard that appears to be applicable
to this provision of the MOA also appears to apply in a limited sense to provision 39 of the
MOA. According to the NCCHC, monitoring of inmates in segregation should be dictated by
the inmate’s degree of isolation. Id. Inmates under extreme isolation63 with little or no contact
with other individuals should be monitored daily by medical staff and at least once a week by
mental health staff. Id. Inmates who are segregated and have limited contact with staff or other
inmates are monitored three days a week by medical or mental health staff. Id. Inmates who are
allowed periods of recreation or other routine social contact among themselves while being
segregated from the general population should be checked weekly by medical or mental health
staff. Id.
It appears that this provision of the MOA imposes requirements relating only to
monitoring of inmates in isolation (as defined by the MOA; see above) by medical staff for
medical and mental health issues, and provision 39 imposes requirements relating to monitoring
of inmates in isolation by mental health staff. This MOA provision requires that medical staff
make daily sick call rounds, and nursing staff make sick call rounds three times per week.
The sick call rounds performed pursuant to this provision of the MOA should
ensure that each isolated inmate has the opportunity to request care for medical or mental health
problems and allow staff to ascertain the inmate’s general medical and mental health status. Id.
The NCCHC standard recommends also that documentation of isolation rounds be made on
individual logs or cell cards, or in an inmate’s health record and include: (1) the date and time of
the contact; and (2) the signature or initials of the health staff member making the rounds. Id.
Finally, any significant health findings should be documented in the inmate’s health record. Id.
B.

Baylor
1.

Findings

62

A “segregated” inmate is one who is isolated from the general population and who receives
services and activities apart from other inmates. J-E-09; P-E-09. Such segregation could include
administrative segregation, protective custody, disciplinary segregation, or a supermax tier. Id.
63

“Extreme isolation” means “situations in which inmates are seen by staff or other inmates
fewer than three times a day.” J-E-09; P-E-09.

64

The Monitoring Team found that isolation rounds were done regularly by mental
health staff and inmates can be transported to a private setting if detailed contact is clinically
indicated.
2.

Assessment

The Monitoring Team did not assess Baylor for compliance with this provision
with regard to the provision of medical services. The Monitoring Team found that Baylor is in
substantial compliance with this provision of the MOA as it relates to mental health services.
C.

DCC
1.

Findings

The Monitoring Team observed that isolation rounds are taking place in a timely
and adequate manner.
2.

Assessment

The Monitoring Team found that DCC is in substantial compliance with this
provision of the MOA.
D.

HRYCI
1.

Findings

The Monitoring Team found that isolation rounds are conducted on a timely basis
(three days a week), and the rounds take one-half to one hour. The Monitoring Team found that
training of clinicians with respect to conducting rounds was inadequate.
2.

Assessment

The Monitoring Team found that HRYCI is in partial compliance with this
provision of the MOA.
E.

SCI
1.

Findings

The Monitoring Team found that isolation rounds are occurring on a timely basis
and are documented. The documentation revealed that the progress notes were identical in
content regardless of the inmate seen and what day of the week the inmate was seen.
2.

Assessment

65

The Monitoring Team found that SCI is in partial compliance with this provision
of the MOA.
F.

Recommendation

At SCI, the Monitoring Team recommends that the State implement selfmonitoring to ensure both timeliness and appropriateness of the assessments.
21.

Grievances
A.

Relevant MOA Provision
Paragraph 21 of the MOA provides:
The State shall develop and implement a system to ensure that medical
grievances are processed and addressed in a timely manner. The State
shall ensure that medical grievances and written responses thereto are
included in inmates’ files, and that grievances and their outcomes are
logged, reviewed, and analyzed on a regular basis to identify systemic
issues in need of redress. The State shall develop and implement a
procedure for discovering and addressing all systemic problems raised
through the grievance system.

This MOA provision requires the State to develop and implement a system to
ensure that medical grievances are processed and addressed in a timely manner. This
requirement is similar to the NCCHC standards, which recommend that there be a grievance
mechanism to address inmates’ complaints about health services. See J-A-11; P-A-11. The State
has developed a grievance policy. See State Policy A-11. The Monitoring Team finds that this
policy is adequate. Appropriate timeliness of processing and addressing grievances is not
defined by the NCCHC standards or the State’s policy.
The NCCHC also recommends that in addition to the formal grievance
mechanism, institutions attempt to informally resolve inmates’ complaints about health services.
J-A-11; P-A-11. The informal dispute resolution can consist of a face-to-face interview by a
Health Services Administrator, responsible physician, or nursing supervisor, and is often an
effective way to resolve problems and demonstrate health staff’s concern. Id. The State has
informed the Monitoring Team that such an informal process has been put in place in at least one
of the Facilities, with the face-to-face meetings occurring with the Health Services
Administrator. The Monitoring Team looks forward to reviewing that process.
This provision of the MOA also requires that the State shall ensure that medical
grievances and written responses thereto are included in inmates’ files. For this requirement of
the MOA, the requirements of provision 3 of the MOA also will apply with respect to timeliness
and appropriateness of filing grievance information in inmates’ medical records.
Finally, this provision of the MOA also requires that the State ensure that
grievances and their outcomes are logged, reviewed, and analyzed on a regular basis to identify

66

systemic issues in need of redress, and to develop and implement a procedure for discovering
and addressing all systemic problems raised through the grievance system. This requirement is
most appropriately addressed in relation to provisions 54 and 55 of the MOA, which relate to the
State’s quality assurance efforts. See J-A-06; P-A-06 (NCCHC standards for continuous quality
improvement programs).
B.

Baylor

The Monitoring Team deferred assessment of Baylor’s compliance with this
provision of the MOA due to changes in the grievance policy that were taking place at the time
of the Monitoring Team’s visit. The Monitoring Team was informed that, although grievances
are supposed to be entered through DACS and transferred to the health care unit from DACS,
after May 2007 there was a period of a few months where this process did not occur. In
September 2007, the health care staff received 48 grievances out of the DACS from custody, and
since that time, the health care unit has made an effort to keep pace with the timelines required
by the grievance policy, which policy was being modified at the time of the Monitoring Team’s
visit.
C.

DCC
The Monitoring Team did not assess DCC’s compliance with this provision of the

MOA.
D.

HRYCI
1.

Findings

The Monitoring Team did not assess HRYCI’s compliance with this provision of
the MOA. Although not assessed, the Monitoring Team had a lengthy discussion with the staff
regarding a grievance program. During that discussion, the Monitoring Team encouraged the
health care administration to develop an informal dispute resolution process that is consistent
with the NCCHC recommendation discussed above. The Monitoring Team has learned that the
State has adopted that recommendation. The Monitoring Team expects that the adoption of the
information process will reduce the number of grievances filed.
The Monitoring Team was informed that when a grievance is filed, the case is
reviewed by the health care staff on site. The Monitoring Team found that to be a reasonable
process, and requested that a tracking process be set up to facilitate future reviews.
E.

SCI
The Monitoring Team did not assess SCI’s compliance with this provision of the

MOA.

67

CHRONIC DISEASE CARE
22.

Chronic Disease Management Program
A.

Relevant MOA Provision
Paragraph 22 of the MOA provides:
The State shall develop and implement a written chronic care disease
management program, consistent with generally accepted professional
standards, which provides inmates suffering from chronic illnesses with
appropriate diagnosis, treatment, monitoring, and continuity of care. As
part of this program, the State shall maintain a registry of inmates with
chronic diseases.

An adequate chronic disease64 management program should identify patients with
chronic diseases with the goal of decreasing the frequency and severity of symptoms, including
preventing disease progression and fostering improvement in function. J-G-02; P-G-02. A
chronic disease program should incorporate a treatment plan and regular clinic visits. Id. The
clinician responsible should monitor the patient’s progress during clinic visits and, when
necessary, change the treatment. Id. The program should also include patient education for
symptom management. Id.
B.

Baylor
1.

Findings

Three weeks prior to the Monitoring Team’s visit, a chronic disease nurse had
been assigned to manage the chronic disease program. As a result, the chronic disease
management program had not yet been worked out fully. Timeliness of patient follow-up
appointments needs some improvement, although the physician is very sensitive to having
patients seen on a timely basis. The Monitoring Team found other instances in which the
assessments of degree of control were not consistent with the NCCHC guidelines. In other
instances, services such as immunizations, which are required by the guidelines, were not
provided.
2.

Assessment

The Monitoring Team found that Baylor is in partial compliance with this
provision of the MOA.
64

A “chronic disease” is defined as “an illness or condition that affects an individual’s wellbeing for an extended interval, usually (at least) 6 months, and generally is not curable but can be
managed to provide optimum functioning within any limitations the condition imposes on the
individual. J-G-02; P-G-02. Examples of a chronic disease include asthma, diabetes, high blood
cholesterol, HIV, hypertension, seizure disorder, and TB. Id. Each chronic disease has a
separate set of clinical guidelines that apply to appropriate treatment and control of the disease.
68

C.

DCC
1.

Findings

The Monitoring Team found that the chronic care list is not completely entered
into the new DACS system yet, which means that appointment scheduling might not be
occurring properly. In addition, a review of records demonstrated missed appointments, which is
a deficiency with regard to the standard of follow-up or continuity. With respect to the quality
of the chronic care being provided, the Monitoring Team found that inmates’ medical histories
are not always complete, and the assessment of the level of control of an inmate’s chronic illness
was not consistently accurate.
2.

Assessment

The Monitoring Team found that DCC is in partial compliance with this provision
of the MOA.
D.

HRYCI
1.

Findings

The Monitoring Team found that physician time is inadequate to see all of the
patients at HRYCI with chronic illnesses. A nurse practitioner has been assigned to see all of the
chronic disease patients from the East Wing of HRYCI. Complicated diseases should be
managed by a physician. HRYCI just initiated its chronic disease program in March 2007, and
the program needs additional time to develop. The Monitoring Team found that support services
for the chronic disease program at HRYCI are deficient. Specifically, medical record, laboratory
and scheduling functions do not serve the clinic well as of the time of the Monitoring Team’s
observations.
2.

Assessment

The Monitoring Team found that HRYCI is in partial compliance with this
provision of the MOA.
E.

SCI
1.

Findings

A review of records revealed that although physical assessments were usually
adequate, the quality of chronic care was not adequate. The Monitoring Team reviewed 20
records of patients with chronic illness. Many of the records reviewed reflected either that no
history had been taken of the patient, or an inadequate history had been taken. Also, the
assessments of the degree of control of the patients’ chronic illnesses frequently were not
consistent with clinical guidelines. The Monitoring Team also noted that the chronic care notes

69

in the inmates’ health records often do not record instances when patients have significant
problems requiring admission to the infirmary.
The Monitoring Team also found that patients with serious chronic diseases were
not well managed. The Monitoring Team believes that this is related to physician performance.
Specifically, the Monitoring Team found that, in certain cases, procedures which should have
been done were not done, symptoms illustrating the worsening of an inmate’s condition were
sometimes ignored, and follow-up visits and further monitoring of patients was not always done
on a timely basis, and in some cases was not done at all. In one case, the patients’ status was
noted in his chart as having improved even though the particular test which served as evidence
for this assessment clearly indicated the contrary. The Monitoring Team spoke with the CMS
State Medical Director, who agreed that physician performance is inadequate and an issue at
SCI.
2.

Assessment

The Monitoring Team found that SCI is in partial compliance with this provision
of the MOA.
F.

Recommendation

At Baylor, the Monitoring Team recommends that the State: (i) draft and
implement policies and procedures to ensure compliance with the chronic care program
requirements; (ii) create a Physician/Chronic Care Nurse team that supports each other’s
activities; and (iii) begin self-monitoring for timeliness of process elements of the guidelines.
At HRYCI, the Monitoring Team recommends that the State: (i) fully implement
the chronic care program; and (ii) begin self-monitoring of the implementation.
At SCI, the Monitoring Team recommends that the State: (i) assign a chronic
care nurse to work with the physician and nurse practitioner to facilitate timeliness of follow-up
and performance of process measures; (ii) the State’s Medical Director is to mentor and review
physician performance; (iii) implement self-monitoring of the chronic care program; and (iv)
ensure linkage between acute episodes and chronic care monitoring and assessments.
23.

Immunizations
A.

Relevant MOA Provision
Paragraph 23 of the MOA provides:
The State shall make reasonable efforts to obtain immunization records for
all juveniles65 who are detained at the Facilities for more than one (1)
month. The State shall ensure that medical staff update immunizations for

65

The term “juveniles” means “individuals detained at a facility who are under the age of
eighteen (18).” See MOA II.H.
70

such juveniles in accordance with nationally recognized guidelines and
state school admission requirements. The physicians who determine that
the vaccination of a juvenile or adult inmate is medically inappropriate
shall properly record such determination in the inmate’s medical record.
The State shall develop policies and procedures to ensure that inmates for
whom influenza, pneumonia and Hepatitis A and B vaccines are medically
indicated are offered these vaccines.
This provision of the MOA requires that the State make reasonable efforts to
obtain immunization records for all juveniles who are detained at the Facilities for more than one
month. This requirement means that the State will need a system to track which juveniles have
been detained for more than one month. Although there are no official guidelines available to
determine what reasonable efforts would be under these circumstances, the Monitoring Team
believes that reasonable efforts would consist of an attempt to acquire the juvenile’s school
records, and records from any health care providers in the community that have provided care to
the juvenile that the State is able to identify after asking the juvenile. The MOA further requires
that, for juveniles, the State ensure that medical staff update immunizations for such juveniles in
accordance with nationally recognized guidelines and state school admission requirements.
Those guidelines and admission requirements are attached hereto as Appendix III.
This provision of the MOA also requires that the State develop procedures to
ensure that inmates for whom influenza, pneumonia and Hepatitis A and B vaccines are
medically indicated are offered these vaccines. For example, influenza vaccine is recommended
to be administered in adults aged 50 and older unless there is evidence of immunity or prior
vaccination. See http://www.cdc.gov/mmwr/pdf/wk/mm5641-Immunization.pdf. Further, if a
physician determines that vaccination of a juvenile or adult inmate is medically inappropriate,
the physician shall properly record such determination in the inmate’s medical record. An
example of when a vaccination might be medically inappropriate is in the case of a pregnant
female and a vaccination that has not been deemed safe for pregnant females to have.
B.

Baylor
The Monitoring Team did not assess Baylor’s compliance with this provision of

the MOA.
C.

DCC
The Monitoring Team did not assess DCC’s compliance with this provision of the

MOA.
D.

HRYCI
The Monitoring Team did not assess HRYCI’s compliance with this provision of

the MOA.
E.

SCI

71

The Monitoring Team did not assess SCI’s compliance with this provision of the
MOA. The Monitoring Team notes, however, that SCI does have a tracking system in place for
immunizations.

72

MEDICATION
24.

Medication Administration
A.

Relevant MOA Provision
Paragraph 24 of the MOA provides:
The State shall ensure that all medications, including psychotropic
medications, are prescribed appropriately and administered in a timely
manner to adequately address the serious medical and mental health needs
of inmates. The State shall ensure that inmates who are prescribed
medications for chronic illnesses that are not used on a routine schedule,
including inhalers for the treatment of asthma, have access to those
medications as medically appropriate. The State shall develop and
implement adequate policies and procedures for medication administration
and adherence. The State shall ensure that the prescribing practitioner is
notified if a patient misses a medication dose on three consecutive days,
and shall document that notice. The State's formulary shall not unduly
restrict medications. The State shall review its medication administration
policies and procedures and make any appropriate revisions. The State
shall ensure that medication administration records (“MARs”) are
appropriately completed and maintained in each inmate’s medical record.

Medications are appropriately prescribed if they are prescribed upon the order of a
physician, dentist, or other legally authorized individual, and only when clinically indicated. JD-02; P-D-02. Administration of medications should be done in a manner that complies with
federal and State of Delaware laws. J-D-01; P-D-01. The NCCHC recommends that institutions
maintain a self-medication program (“keep-on-person”),66 which permits inmates to carry
medications necessary for the emergency management of a condition as appropriate. J-D-01; PD-01.
This provision of the MOA further requires that the State develop and implement
policies and procedures for medication administration and adherence. Also, the State shall
review its medication administration policies and procedures and make any appropriate
revisions. The Monitoring Team finds that the State has adopted appropriate policies. See State
Policy D-02.
B.

Baylor
1.

Findings

The Monitoring Team observed the nursing staff at medication call (i.e., when
inmates come to a window to receive medication) and medication administration (i.e., when the
66

“Self-medication programs” are programs which “permit responsible inmates to carry and
administer their own medications.” J-D-02; P-D-02.
73

nurses bring medication to inmates in their cells). The Monitoring Team observed that the
nurses were not following standard nursing practices in administering medications. Specifically,
the Monitoring Team observed that as inmates approached the window to receive medication, the
LPN administering medications retrieved the medication blister-pack and punched out a pill into
a cup, without comparing the MAR against the medication label on the blister-pack. The MAR
should have the most current medication orders on it. If a medication was changed or
discontinued, the nurse administering medications would not know this simply by administering
medications from the blister-pack. Also, the nurse did not document administration of
medications until the end of pill call.
The Monitoring Team also observed the evening shift nurse, and observed her
pre-pouring medications into soufflé cups and writing the inmate’s name on it without other
necessary information such as the name and dosage of the medication. The nurse also signed
that she had given the medication to an inmate in advance of medication administration. She had
also saved approximately ten soufflé cups of medication for inmates who had not come to pill
call to take their medications two days prior. She planned to use those medications to administer
them that evening. This presents a risk of medication error.
2.

Assessment

The Monitoring Team found that Baylor is in partial compliance with this
provision of the MOA.
C.

DCC
1.

Findings

Overall, medication administration is challenging due to the size of DCC, the
institutional schedule, the multiple locations for medication administration, and the number of
staff allocated to perform this function. Due to the fact that there are just two nurses on each
shift (sometimes a third for afternoon medication administration) responsible for administering
medications, this process takes place almost 24 hours a day.
The Monitoring Team spoke with the Director of Nurses. The Director of Nurses
informed them that the first medication administration round begins at 2:30 a.m. for pretrial
detainees. Despite the institutional schedule, requiring patients to get up at 2:30 a.m. is not
reasonable and reflects inadequate staff to carry out this mission on a more reasonable schedule.
Moreover, because of the multiple times and locations of medication administration, the timing
of medication administration is not documented properly in inmate’s MARs.
The Monitoring Team observed a nurse preparing medications for administration,
and noted that she failed to observe appropriate procedure. Specifically, the nurse did not use the
MAR and compare it to the blister-pack at the time she prepared the medications. This may lead
to medication errors if the order was changed and the new blister pack had not arrived. The
MARs showed that nurses were generally consistent in documenting medication administration,
but most had blank spaces where nurses did not document the medication administration status

74

(administered, refused, etc.) In addition, nurses do not consistently document the discontinuation
of medication orders.
The Monitoring Team also found that MARs that document receipt of selfadministered medications (antihypertensive, seizure medications, etc.) are not filed into inmate’s
medical record in a timely manner. For example, some MARs from March 2007 were still not
filed in October 2007 when the Monitoring Team visited DCC. As a result, clinicians are not
reliably able to assess medication continuity and compliance from review of the record.
The Monitoring Team found that DCC is not in compliance with this provision of
the MOA as it relates to the medication administration of mental health medications. The
Monitoring Team found that psychiatrists are not learning about patient non-compliance with
medication regimens, which can result in decompensation of an inmate’s mental health status
without a psychiatrist learning about it. In addition, stock medications periodically run out,
which results in a lapse in treatment.
2.

Assessment

The Monitoring Team found that DCC is in partial compliance with this provision
of the MOA.
D.

HRYCI
1.

Findings

The Monitoring Team observed significant problems in the medication
administration process. In addition, staff acknowledged to the Monitoring Team that there is a
lack of compliance with the policy regarding notifying physicians about non-compliance with
medication. The Monitoring Team also found that MARs are often not legible or timely filed.
Finally, the Monitoring Team found that although staff had knowledge regarding policies for the
timely renewal of expiring medications and informed consent, the Monitoring Team was unable
to determine if staff actually puts these policies into practice.
2.

Assessment

The Monitoring Team found that HRYCI is not in compliance with this provision
of the MOA.
E.

SCI
1.

Findings

The Monitoring Team observed that medication administration is not done
according to acceptable nursing practices. For example, the nurses document on the MAR that
medication is received before the patient has actually come to receive the medication. Thus, if

75

the patient does not come to receive medication, it is left to the memory of the nurse
administering the medication to return to the MAR to mark that inmate as absent.
2.

Assessment

The Monitoring Team found that SCI is in partial compliance with this provision
of the MOA.
F.

Recommendation

At Baylor, the Monitoring Team recommends that the State: (i) draft and
implement policies and procedures to ensure appropriate medication administration and
documentation consistent with State nursing practices; and (ii) begin self-monitoring of these
practices.
Under the circumstances described above, the Monitoring Team recommends that
the State, DCC’s institutional leadership, and CMS leadership reassess the system for medication
administration at DCC. The end result should be policy and procedure and practice that
administers medications to inmates at reasonable hours and predictable times; and accurately
documents administration status on the medication administration record that is filed in the
health record in a timely manner. Staffing, mechanisms of delivery and perhaps institutional
schedules may require adjustment to accomplish this goal. Many correctional systems administer
medications on an approximate schedule of 6 a.m., 12 noon, 4 p.m. and 8 p.m. Exceptions are
made for insulin-dependent inmates or in cases where meals conflict with medication
administration requirements (e.g., insulin administered prior to meals or medications that must
be administered with or without meals). Regardless, medications should be administered within a
one-hour window period of designated times. Nurses must prepare medications in accordance
with standard nursing practice by comparing the current MAR against the medication blister
pack, administering medications from legal containers (not handwritten envelopes), and
documenting administration at the time the medication is given to the patient, not before or after.
Also at DCC, the Monitoring Team recommends that the State: (i) create a plan
that achieves reliable medication administration within reasonable time frames and in a manner
that addresses the health needs of all patients, including those with insulin-dependent diabetes,
mental illness, or other special needs; (ii) create a plan which will provide a list of all
psychotropic non-formulary requests approved in the last three months, and information
regarding how long the process takes from initiation to administration of the first dose; and (iii)
perform a study which documents the average time frame for ordering non-formulary medication
to patient receipt of such medication.
At HRYCI, the Monitoring Team recommend that the State: (i) implement
procedures that address the areas identified in the findings section above adequately; and (ii)
monitor for compliance with its policies.
At SCI, the Monitoring Team recommends that the State: (i) redesign the process
so that documentation of medication administration occurs at the time of administration; and (ii)

76

create a plan that includes custody participation in mouth checks at the time of medication
administration.
25.

Continuity of Medication
A.

Relevant MOA Provision
Paragraph 25 of the MOA provides:
The State shall ensure that arriving inmates who report that they have been
prescribed medications shall receive the same or comparable medication
as soon as is reasonably possible, unless a medical professional determines
such medication is inconsistent with generally accepted professional
standards. If the inmate’s reported medication is ordered discontinued or
changed by a medical professional, a medical professional shall conduct a
face-to-face evaluation of the inmate as medically appropriate.

This provision of the MOA is meant to ensure continuity of care from the entry of
an inmate into a facility. J-E-12; P-E-12. Further, this provision can assist with preventing
adverse patient outcomes, which are more likely to happen with respect to medication services
practices when a provider frequently changes orders, the provider fails to review patient
medication histories, or treating staff are unaware of each other’s prescribing behaviors. J-D-02;
P-D-02.
B.

Baylor
1.

Findings

The Monitoring Team found that, based upon a review of records and staff
interviews, physician orders for medications are not consistently transcribed in a timely manner.
Also, medications are not administered in a timely manner following order transcription.
Additionally, the Monitoring Team found multiple instances where inmates who entered the
facility indicated they were on certain medications. However, their records show that they did
not start receiving their medication at the facility until one to two weeks after first entering.
2.

Assessment

The Monitoring Team found that Baylor is in partial compliance with this
provision of the MOA.
C.

DCC

The Monitoring Team did not assess DCC’s compliance with this provision of the
MOA. The Monitoring Team found that MARs are not timely filed in inmate files, which
inhibited the Monitoring Team’s ability to monitor this provision of the MOA.

77

Also, bridge orders upon intake for psychotropic medications were often not
initiated by medical staff. A bridge order is an order for medications the person took outside the
facility that is usually verified by jail nursing staff and then issued by a physician until the person
is scheduled to be seen by a psychiatrist on site. That way there is as little disruption in their
care as possible. In general, medications should be ordered that are the same preparation the
person took outside the facility and not altered until a psychiatrist actually evaluates the
individual and in their clinical judgment changes in prescriptions are safe and equally effective
as the prior medication.
D.

HRYCI
The Monitoring Team did not assess HRYCI’s compliance with this provision of

the MOA.
E.

SCI
1.

Findings

The Monitoring Team found problems with chronic care patients and inmates
receiving other services being able to receive medications in a timely fashion. This occurred
with both formulary and non-formulary medications; thus, the problem does not arise solely from
a delay in ordering non-formulary medications. Additionally, the Monitoring Team found
multiple instances where inmates who entered the facility indicated they were on certain
medications. However, their records show that they did not start receiving their medication at
the facility until one to two weeks after first entering.
2.

Assessment

The Monitoring Team found that SCI is in partial compliance with this provision
of the MOA.
F.

Recommendation

At Baylor, the Monitoring Team recommends that the State: (i) implement
policies and procedures to ensure timely receipt of medication from the time of order; (ii) begin
self-monitoring of medication continuity for timeliness.
At DCC, the Monitoring Team recommends that the State: (i) draft and
implement procedures to ensure timely filing of MAR documents; (ii) implement self-monitoring
of nursing performance with regard to actual and documented medication administration; and
(iii) implement a procedure to ensure intake-generated bridge orders resulting in timely
medication receipt by patients.
At HRYCI, the Monitoring Team recommends that the State implement a
procedure to ensure intake-generated bridge orders resulting in timely medication receipt by
patients.

78

At SCI, the Monitoring Team recommends that the State: (i) implement
procedures that mitigate medication discontinuity on entry to the facility; and (ii) implement a
self-monitoring system.
26.

Medication Management
A.

Relevant MOA Provision
Paragraph 26 of the MOA provides:
The State shall develop and implement guidelines and controls regarding
the access to, and storage of, medication as well as the safe and
appropriate disposal of medication and medical waste.
The guidelines and controls developed by the State should include the following

components:
•

The Facility complies with all applicable state and federal regulations with
regard to prescribing, dispensing, administering, and procuring
pharmaceuticals;

•

The facility maintains a formulary for providers;

•

The facility maintains procedures for the timely procurement, dispensing,
distribution, accounting, and disposal of pharmaceuticals;

•

The facility maintains records as necessary to ensure adequate control of
and accountability for all medications;

•

The facility maintains maximum security storage of, and accountability by
use for, Drug Enforcement Agency (DEA)-controlled substances;

•

The facility has an adequate method for notifying the responsible
practitioner of the impending expiration of a drug order, so that the
practitioner can determine whether the drug administration is to be
continued or altered;

•

Medications are kept under the control of appropriate staff members;

•

Inmates do not prepare, dispense, or administer medication except for selfmedication programs approved by the facility administrator and
responsible physician (e.g., “keep-on-person” programs). Inmates are
permitted to carry medications necessary for the emergency management
of a condition when ordered by a clinician;

79

•

Drug storage and medication areas are devoid of outdated, discontinued,
or recalled medications;

•

Where there is no staff pharmacist, a consulting pharmacist is used for
documented inspections and consultation on a regular basis, not less than
quarterly;

•

All medications are stored under proper conditions of sanitation,
temperature, light, moisture, ventilation, segregation, and security.
Antiseptics, other medications for external use, and disinfectants are
stored separately for internal and injectable medications. Medications
requiring special storage for stability (e.g., medications that need
refrigeration are so stored);

•

An adequate and proper supply of antidotes and other emergency
medications, and related information (including posting of the poison
control telephone number in areas where overdoses or toxicologic
emergencies are likely) are readily available to the staff.

J-D-01; P-D-01.
B.

Baylor
1.

Findings

At the time of the Monitoring Team’s visit to Baylor to monitor this provision,
policies related to medication administration and management had not yet been finalized. The
Monitoring Team observed that medications were administered from a small, cramped room that
has a window opening into the main hallway. The medications and syringes are not in a secure
environment, as the medication cabinets are not locked, and one was even missing a door. There
is also no system of accountability for needles and syringes.
In addition, there is no accountability system for stock medications. The nurses
do not document on a form each time stock medications are given out. This causes a risk of
diversion of medications.
Narcotics are kept in a locked cabinet. The Monitoring Team found that two out
of five narcotic counts were not correct. The Monitoring Team found that nurses were not
following proper procedure for signing out the narcotics at the time of administration.
Specifically, the nurse was not signing out narcotics at the time of administration of the
narcotics, and administered narcotics from a blister pack that had been dispensed for a specific
inmate to any inmate that was supposed to be on that narcotic medication. These practices are
inconsistent with appropriate nursing practices, and possibly State of Delaware laws. See e.g.,
16 Del. C. §§ 4701, et seq. and accompanying regulations at 24 Del. Admin. Uniform Controlled

80

Substance Act Regulations. Further, the documentation regarding administration of narcotics
revealed serious errors.
2.

Assessment

The Monitoring Team found that Baylor is in partial compliance with this
provision of the MOA.
C.

DCC
1.

Findings

The Monitoring Team found that the medication room has adequate space, but it
is somewhat cluttered, and organization needs to be improved. External and internal medications
are not separated and labeled. A random sample of injectable medications revealed that two out
of ten medications had expired. Finally, DCC lacks a reliable system for needle and syringe
accountability.
2.

Assessment

The Monitoring Team found that DCC is in partial compliance with this provision
of the MOA.
D.

HRYCI
1.

Findings

The Monitoring Team observed that the medication room at HRYCI is
disorganized and has cabinets with broken locks. There is also a hole in the ceiling. HRYCI
also lacks an adequate system for accountability of narcotics, needles and syringes. Staff is
required to account for lancets for checking capillary blood glucose levels on diabetics. This
should not be required and takes up too much of staff time.
Also, there is not an adequate system for accountability of narcotics. Narcotics
prescribed for individual inmates were being used for stock supplies.
2.

Assessment

The Monitoring Team found that HRYCI is in partial compliance with this
provision of the MOA.
E.

SCI
The Monitoring Team did not assess SCI’s compliance with this provision of the

MOA.

81

F.

Recommendation

At Baylor, the Monitoring Team recommends that the State: (i) create a plan that
addresses issues enumerated in the Findings above; (ii) implement the above plan; and (iii) begin
self-monitoring.
At DCC, the Monitoring Team recommends that the State draft and implement
procedures that ensure a clean and well-organized medication room, as well as monitoring of
medication expirations and sharps control.
At HRYCI, the State recommends that the State create a plan to ameliorate the
problems found in the medication room, the sharps control, and controlled substance
accountability.

82

EMERGENCY CARE
27.

Access to Emergency Care
A.

Relevant MOA Provision
Paragraph 27 of the MOA provides:
The State shall train medical, mental health and security staff to recognize
and respond appropriately to medical and mental health emergencies.
Furthermore, the State shall ensure that inmates with emergency medical
or mental health needs receive timely and appropriate care, including
prompt referrals and transports for outside care when medically necessary.

The NCCHC recommends that the provision of 24-hour emergency medical,
mental health, and dental services. J-E-08; P-E-08. In order to ensure timely and appropriate
emergency services, the NCCHC recommends that institutions have a written plan including
arrangements for emergency transport of the patient from the facility, use of an emergency
medical vehicle, use of one or more designated hospital emergency departments or other
appropriate facilities, emergency on-call physician, mental health, and dental services when the
emergency health care facility is not located nearby, security procedures for the immediate
transfer of patients for emergency medical care, and notification to the person legally responsible
for the facility. Id. Further, emergency drugs, supplies, and medical equipment are regularly
maintained. Id.
B.

Baylor
1.

Findings

The Monitoring Team found that patients are sent to outside hospitals for
emergencies on a timely basis. However, all laboratory testing is routine even when urgent
laboratory testing is indicated. Urgent medical evaluations occasionally are not recorded
especially for persons detoxifying from alcohol.
2.

Assessment

The Monitoring Team found that Baylor is in partial compliance with this
provision of the MOA.
C.

DCC
1.

Findings

DCC established an urgent care log in December 2007, which lists the names of
patients who require urgent care, their medical problems, and the dispositions of their care (i.e. if
they are sent to the hospital, etc.). As a result of the newness of the program, the Monitoring

83

Team was unable to pull records with regard to urgent problems. A review of the new DACS
system did provide some records for the Monitoring Team to review, and one of three of those
records revealed an issue regarding the follow-up care provided to that patient.
2.

Assessment

The Monitoring Team found that DCC is in partial compliance with this provision
of the MOA.
D.

HRYCI
1.

Findings

The Monitoring Team found that the on-site emergency evaluations by nurses and
physicians are not of good quality, but there are no impediments to patients being sent to local
emergency rooms. The Monitoring Team noted that when patients return from emergency visits,
no record accompanies the patient and follow-up is not good.
The Monitoring Team found that psychiatric emergencies are managed initially at
the infirmary, with mental health staff reporting emergencies up the chain of command as
appropriate. HRYCI refers cases that it cannot handle to the Delaware Psychiatric Center, but
space is limited there, and the process of referring inmates to that facility is logistically
burdensome. The Monitoring Team found that, on occasion, inmates with psychiatric
emergencies are sent to a community emergency room.
2.

Assessment

The Monitoring Team found that HRYCI is in partial compliance with this
provision of the MOA with regard to emergency evaluations by medical staff. The Monitoring
Team found that HRYCI is in substantial compliance with this provision of the MOA with
regard to emergency evaluations by mental health staff.
E.

SCI
1.

Findings

The Monitoring Team found that there did not appear to be any impediment to
transportation of patients to the hospital once a referral was made, but that emergency
evaluations on-site by nurses were not adequate. For example, one patient reviewed by the
Monitoring Team had a history of a serious heart issue and had four episodes, each of which
should have resulted in a cardiology consultation but instead was not evaluated. However, the
Monitoring Team found that there did not appear to be any impediment to transportation of
patients to the hospital once such transportation was ordered.
2.

Assessment

84

The Monitoring Team found that SCI is in partial compliance with this provision
of the MOA.
F.

Recommendation

The Monitoring Team recommends that the State create a plan to address the
deficiencies described above.
28.

First Responder Assistance
A.

Relevant MOA Provision
Paragraph 28 of the MOA provides:
The State shall train all security staff to provide first responder assistance
(including cardiopulmonary resuscitation (“CPR”) and addressing serious
bleeding) in an emergency situation. The State shall provide all security
staff with the necessary protective gear, including masks and gloves, to
provide first line emergency response.

This provision of the MOA defines the complete standard for first responder
assistance. For further information, see discussions of provisions 9, 32, and 52.
B.

Baylor
The Monitoring Team did not assess Baylor’s compliance with this provision of

the MOA.
C.

DCC
The Monitoring Team did not assess DCC’s compliance with this provision of the

MOA.
D.

HRYCI
The Monitoring Team did not assess HRYCI’s compliance with this provision of

the MOA.
E.

SCI
The Monitoring Team did not assess SCI’s compliance with this provision of the

MOA.

85

MENTAL HEALTH CARE
29.

Treatment
A.

Relevant MOA Provision
Paragraph 29 of the MOA provides:
The State shall ensure that qualified mental health professionals provide
timely, adequate, and appropriate screening, assessment, evaluation,
treatment and structured therapeutic activities to inmates requesting
mental health services, inmates who become suicidal, and inmates who
enter with serious mental health needs or develop serious mental health
needs while incarcerated.

This provision of the MOA is an overall standard governing the timeliness and
appropriateness of the following components of mental health care to be provided at the
Facilities:
•

mental health screening;

•

assessment;

•

evaluation;

•

treatment; and

•

structured therapeutic activities.

The NCCHC recommends that there be mental health services67 available for all
inmates who require them. The MOA, on the other hand, requires that mental health services be
available to all inmates requesting them, inmates who become suicidal, and inmates who enter
with serious mental health needs or develop serious mental health needs while incarcerated. J-G04; P-G-04. The NCCHC standards state that mental health treatment is more than prescribing
psychotropic medications; treatment goals include the development of self-understanding, selfimprovement, and development of skills to cope with and overcome disabilities associated with
various mental disorders. Id. The NCCHC provides that facilities housing significant numbers
of patients with mental health problems with longer lengths of stay are expected to offer more
extensive mental health programming. Id. Correctional facilities that provide for the needs of
patients requiring psychiatric hospitalization levels of care are expected to mirror treatment
provided in inpatient settings in the community. Id.

67

“Mental health services” includes “the use of a variety of psychosocial and pharmacological
therapies, either individual or group, including biological, psychological, and social, to alleviate
symptoms, attain appropriate functions, and prevent relapse.”
86

B.

Baylor
1.

Findings

The Monitoring Team found that mental health staff responds rapidly to referrals
from the intake area and sick call requests. There remains a paucity of ongoing mental health
counseling throughout the facility, however.
2.

Assessment

The Monitoring Team found that Baylor is in partial compliance with this
provision of the MOA.
C.

DCC
1.

Findings

The problems identified by the Monitoring Team in relation to DCC’s ability to
comply with this provision of the MOA are detailed throughout this report and include: (i)
inadequate clinic space and equipment; (ii) mental health staffing shortages, including
psychiatric coverage; (iii) lack of depth in the treatment services being provided to inmates; (iv)
significant medication management issues; (v) inadequate grievance system; and (vi)
problematic mental health referral system. Finally, one other problem is an issue with respect to
access to inpatient psychiatric hospitalization for inmates in need of such treatment due to lack of
space at the Delaware Psychiatric Center.
2.

Assessment

The Monitoring Team found that DCC is in partial compliance with this provision
of the MOA.
D.

HRYCI
1.

Findings

The problems identified by the Monitoring Team in relation to HRYCI’s ability to
comply with this provision of the MOA are detailed throughout this report and include: (i)
inadequate clinic space and equipment; (ii) mental health staffing shortages, including
psychiatric coverage; (iii) lack of depth in the treatment services being provided to inmates; and
(iv) significant medication management issues. Finally, one other problem is an issue with
respect to access to inpatient psychiatric hospitalization for inmates in need of such treatment
due to lack of space at the Delaware Psychiatric Center.
2.

Assessment

87

The Monitoring Team found that HRYCI is in partial compliance with this
provision of the MOA.
E.

SCI
1.

Findings

The Monitoring Team found that SCI conducts receiving screening, assessments,
and some group counseling. The Monitoring Team found that treatment consists primarily of
medication administration, and consequently, almost all mental health notes and treatment plans
solely address this issue. A few structured activities are offered by the mental health staff, but
those consist of only three groups for a facility housing approximately 1,200 inmates. The group
counseling that was offered at the time of the Monitoring Team’s visit was inadequate given the
size of SCI.
The Monitoring Team found that documentation continues to demonstrate a
paucity of detail regarding the patient’s historical data and descriptors of the current
symptomatology.
The Monitoring Team also found that follow-up visits are not occurring on a
timely basis after a new diagnosis is made or medication is prescribed and initiated. A timely
follow-up would be within two to three weeks, but patients at SCI are being seen on a quarterly
basis. Quarterly follow-up visits would be timely only in the case of a patient who is stable on
an established regimen.
2.

Assessment

The Monitoring Team found that SCI is in partial compliance with this provision
of the MOA.
F.

Recommendation

The Monitoring Team recommends that the State create plans for each of the
Facilities in order to address the problems identified in the findings above.
30.

Psychiatrist Staffing
A.

Relevant MOA Provision
Paragraph 30 of the MOA provides:
The State shall retain sufficient psychiatrists to enable the Facilities to
address the serious mental health needs of all inmates with timely and
appropriate mental health care consistent with generally accepted
professional standards. This shall include retaining appropriately licensed
and qualified psychiatrists for a sufficient number of hours per week to see

88

patients, prescribe and adequately monitor psychotropic medications,
participate in the development of individualized treatment plans for
inmates with serious mental health needs, review charts in the context of
rendering appropriate mental health care, review and respond to the results
of diagnostic and laboratory tests, and be familiar with and follow
policies, procedures, and protocols. The psychiatrist shall collaborate with
the chief psychologist in mental health services management as well as
clinical treatment, shall communicate problems and resource needs to the
Warden and chief psychologist, and shall have medically appropriate
autonomy for clinical decisions at the facility. The psychiatrist shall
supervise and oversee the treatment team.
This provision of the MOA does not differ significantly from the standards
applicable to provision 6 of the MOA with respect to the requirement for sufficient
psychiatrist staffing, and therefore, the Monitoring Team refers to the standards set forth
with respect to that provision. See J-C-07; P-C-07.
B.

Baylor

The Monitoring Team did not assess Baylor’s compliance with this provision of
the MOA. At the time of the Monitoring Team’s visit, they were not able to meet with the staff
psychiatrist in order to discuss her interactions with the mental health staff. The Monitoring
Team has learned, however, that there are approximately 20 hours per week of psychiatry time
for a case load of 104 women. The Monitoring Team has not had the opportunity to assess the
adequacy of that time.
C.

DCC
1.

Findings

At the time of the Monitoring Team’s visit, the total psychiatric allocation was 60
hours per week, divided among four physicians and housing units. All but one of the
psychiatrists do not have set days of work. Based upon interviews with line staff, the
unpredictability of the psychiatrists’ time has resulted in a barrier to inmate access to the
psychiatrist time. The Monitoring Team found that psychiatrist staffing at DCC is inadequate,
especially given the unpredictable hours the psychiatrist is available.
2.

Assessment

The Monitoring Team found that DCC is in partial compliance with this provision
of the MOA.
D.

HRYCI
1.

Findings

89

The Monitoring Team found that psychiatrist time is inadequate. At the time of
the Monitoring Team’s visit, there were 40 hours of psychiatrist time per week, which was
divided between two psychiatrists who cover at least three days per week. The Monitoring Team
believes that the psychiatrist allocation should be 1.5 (“FTE”) with at least six days per week
coverage, most of which should be provided during regular business hours.
With respect to the psychiatrists’ participation in the development of
individualized treatment plans, the Monitoring Team found that the treatment plans were
developed at the time of the inmate meeting with the counselor and psychiatrist and all sign the
treatment plan. Sometimes the treatment plan is developed without the psychiatrist, and
therefore, is submitted to the psychiatrist to review at a later date.
2.

Assessment

The Monitoring Team found that HRYCI is in partial compliance with this
provision of the MOA.
E.

SCI
1.

Findings

The Monitoring Team found that there are 24 hours of psychiatrist time divided
among 220 inmates, most of whom are seen every 90 days. In a stable population that amount of
time might be adequate, but given the mixed nature of the population at SCI (pretrial detainees
and sentenced inmates), more psychiatrist time is warranted.
2.

Assessment

The Monitoring Team found that SCI is in partial compliance with this provision
of the MOA.
F.

Recommendation

At DCC, the Monitoring Team recommends that the State create a plan that
ensures timely patient access to services at least six days per week.
At HRYCI, the Monitoring Team recommends that the State create a plan that
allows for more psychiatric involvement in the program, especially during normal work hours.
Most likely 1.5 FTE psychiatrists divided over six days would be sufficient.
At SCI, the Monitoring Team recommends that, given the additional visits which
will be required if a more aggressive schedule of follow-up is implemented post treatment
initiation, the State should create a plan to adjust the number of psychiatric hours per week.
31.

Administration of Mental Health Medications
A.

Relevant MOA Provision
90

Paragraph 31 of the MOA provides:
The State shall develop and implement policies, procedures, and practices
consistent with generally accepted professional standards to ensure that
psychotropic medications are prescribed, distributed, and monitored
properly and safely and consistent with generally accepted professional
standards. The State shall ensure that all psychotropic medications are
administered by qualified medical professionals or other health care
personnel qualified under Delaware state law to administer medications,
who consistently implement adequate policies and procedures to monitor
for adverse reactions and potential side effects and to adequately
document the administration of such medications in the MARs.
Documentation in the MARs shall include a clear and consistent indication
of whether the inmate refused or otherwise missed any doses of
medication, as well as doses consumed. As part of the quality assurance
program set forth in Section V of this Agreement, a qualified medical
professional or registered nurse supervisor shall review MARs on a
regular and periodic basis to determine whether policies and procedures
are being followed.
The MOA provides that the State shall develop and implement policies,
procedures, and practices consistent with generally accepted professional standards to ensure that
psychotropic medications are prescribed, distributed, and monitored properly and safely and
consistent with generally accepted professional standards. The State has developed policies
consistent with generally accepted professional standards and the requirements of the MOA. See
Policy D-02.
The State shall ensure that all psychotropic medications are administered by
qualified medical professionals or other health care personnel qualified under Delaware state law
to administer medications, who consistently implement adequate policies and procedures to
monitor for adverse reactions and potential side effects and to adequately document the
administration of such medications in the MARs. According to the MOA, adequate
documentation in the MARs shall include a clear and consistent indication of whether the inmate
refused or otherwise missed any doses of medications, as well as doses consumed. These
standards have been addressed with respect to provisions 24 and 25 of the MOA.
The MOA also requires that the State have a qualified medical professional or
registered nurse supervisor review MARs on a regular and periodic basis to determine whether
policies and procedures are being followed. This can take place as a part of the CQI process.
See discussion of paragraph 54.
B.

Baylor
1.

Findings

91

Almost all medications are administered at the pharmacy window. The
Monitoring Team observed that psychotropic medications are being initiated at unduly high
initial doses and without early review of the response to treatment. In addition, internal audits
from September 2007 show only a 57% compliance rate with medication orders being obtained
within 24 hours of intake medication verification, and 53% receiving their first dose within 24
hours following a physician’s order.
2.

Assessment

The Monitoring Team found that Baylor is in partial compliance with this
provision of the MOA.
C.

DCC
1.

Findings

The Monitoring Team bases this assessment on the same findings that are
discussed with reference to paragraphs 2, 24, 25, and 54 of the MOA.
2.

Assessment

The Monitoring Team found that DCC is in partial compliance with this provision
of the MOA.
D.

HRYCI
1.

Findings

The Monitoring Team bases this assessment on the same findings that are
discussed with reference to paragraphs 2, 24, 25, and 54 of the MOA.
2.

Assessment

The Monitoring Team found that HRYCI is in partial compliance with this
provision of the MOA.
E.

SCI
The Monitoring Team did not assess SCI’s compliance with this provision of the

MOA.
F.

Recommendation

The Monitoring Team recommends that, at Baylor, the State change the practice
to ensure that initial dosing is appropriate and is monitored timely during the initial period to
facilitate patient adherence.

92

32.

Mental Illness Training
A.

Relevant MOA Provision
Paragraph 32 of the MOA provides:
The State shall conduct initial and periodic training for all security staff on
how to recognize symptoms of mental illness and respond appropriately.
Such training shall be conducted by a qualified mental health professional,
registered psychiatric nurse, or other appropriately trained and qualified
individual, and shall include instruction on how to recognize and respond
to mental health emergencies.

This provision of the MOA does not differ significantly from provision 9 of the
MOA, and therefore, the Monitoring Team refers to the standards set forth with respect to that
provision. Also, the Monitoring Team notes that correctional officers should be trained at least
every two years with respect to recognizing signs and symptoms of mental illness. J-C-04; P-C04.
B.

Baylor
1.

Findings

See discussion of paragraph 9.
2.

Assessment

The Monitoring Team found that Baylor is in substantial compliance with this
provision of the MOA.
C.

DCC
1.

Findings

See discussion of paragraph 9.
2.

Assessment

The Monitoring Team found that DCC is in substantial compliance with this
provision of the MOA.
D.

HRYCI
1.

Findings

93

See discussion of paragraph 9.
2.

Assessment

The Monitoring Team found that HRYCI is in substantial compliance with this
provision of the MOA.
E.

SCI
1.

Findings

See discussion of paragraph 9.
2.

Assessment

The Monitoring Team found that SCI is in substantial compliance with this
provision of the MOA.
33.

Mental Health Screening
A.

Relevant MOA Provision
Paragraph 33 of the MOA provides:
The State shall develop and implement adequate policies, procedures, and
practices consistent with generally accepted correctional mental health
care standards to ensure that all inmates receive an adequate initial mental
health screening by appropriately trained staff within twenty-four (24)
hours after intake. Such screening shall include an individual private
(consistent with security limitations) interview of each incoming inmate,
including whether the inmate has a history of mental illness, is currently
receiving or has received psychotropic medications, has attempted suicide,
or has suicidal propensities. Documentation of the screening shall be
maintained in the appropriate medical record. Inmates who have been on
psychotropic medications prior to intake will be assessed by a psychiatrist
as to the need to continue those medications, in a timely manner, no later
than 7-10 days after intake or sooner if clinically appropriate. These
inmates shall remain on previously prescribed psychotropic medications
pending psychiatrist assessment. Incoming inmates who are in need of
emergency mental health services shall receive such care immediately
after intake. Incoming inmates who require resumption of psychotropic
medications shall be seen by a psychiatrist as soon as clinically
appropriate.

The NCCHC recommends that individuals conducting the receiving screening
(see discussion of provision 10 of the MOA) make adequate efforts to explore the potential for

94

suicide. J-E-02; P-E-02. Both reviewing with an inmate any history of suicidal behavior and
visually observing the inmate’s behavior (delusions, hallucinations, communication difficulties,
speech and posture, impaired level of consciousness, disorganization, memory defects,
depression, or evidence of self-mutilation) should be done at the screening. Id.
Within 24 hours after the intake screening takes place, the initial mental health
screening should take place and include a structured interview with inquiries into:
z

a history of:
o
o
o
o
o
o
o

z

psychiatric hospitalization and outpatient treatment;
suicidal behavior;
violent behavior;
victimization;
special education placement;
cerebral trauma or seizures, and
sex offenses; and

the current status of:
o
o
o
o

psychotropic medications;
suicidal ideation;
drug or alcohol use, and
orientation to person, place, and time;

•

emotional response to incarceration; and

•

a screening for intellectual functions (i.e.,
developmental disability, learning disability).

mental

retardation,

J-E-05; P-E-05. The NCCHC further recommends that the inmate’s health record contains
results of the initial screening. Id.
B.

Baylor
1.

Findings

The Monitoring Team found that mental health screenings were complete and
appropriate referrals were made to mental health.
2.

Assessment

The Monitoring Team found that Baylor is in substantial compliance with this
provision of the MOA.
C.

DCC

95

1.

Findings

The Monitoring Team found that appropriate policies are in place, but the
implementation has been problematic as described in other portions of this report.
2.

Assessment

The Monitoring Team found that DCC is in partial compliance with this provision
of the MOA.
D.

HRYCI
1.

Findings

The Monitoring Team found that appropriate policies are in place at HRYCI, but
their implementation has been problematic as described in other sections of this report.
2.

Assessment

The Monitoring Team found that HRYCI is in partial compliance with this
provision of the MOA.
E.

SCI
1.

Findings

The Monitoring Team measured the timeliness of the psychiatric review by
measuring the time against the referral by the mental health staff. The Monitoring Team found
that mental health screenings are consistently completed in a timely fashion, and mental health
referrals are reliably generated through DACS.
2.

Assessment

The Monitoring Team found that SCI is in substantial compliance with this
provision of the MOA.
F.

Recommendation

The Monitoring Team recommends that the State implement a procedure to
ensure timely and appropriate screening and follow-up, including for bridge medications. See
also recommendation for MOA ¶ 10.
34.

Mental Health Assessment and Referral
A.

Relevant MOA Provision

96

Paragraph 34 of the MOA provides:
The State shall develop and implement adequate policies, procedures, and
practices consistent with generally accepted professional standards to
ensure timely and appropriate mental health assessments by qualified
mental health professionals for those inmates whose mental health
histories, or whose responses to initial screening questions, indicate a need
for such an assessment. Such assessments shall occur within seventy-two
(72) hours of the inmate’s mental health screening or the identification of
the need for such assessment, whichever is later. The State shall also
ensure that inmates have access to a confidential self-referral system by
which they may request mental health care without revealing the substance
of their request to security staff. Written requests for mental health
services shall be forwarded to a qualified mental health professional and
timely evaluated by him or her. The State shall ensure adequate and
timely treatment for inmates whose assessments reveal serious mental
illness, including timely and appropriate referrals for specialty care and
regularly scheduled visits with qualified mental health professionals.
Any inmates with positive screenings for mental health problems should be
referred to qualified mental health professionals for further evaluation. J-G-04; P-G-04. The
health record should contain the results of the evaluations with documentation of referral or
initiation of treatment when indicated. Id. Patients with needs that require acute mental health
services beyond those available at the facility are transferred to an appropriate facility. Id.
B.

Baylor
1.

Findings

The Monitoring Team found that inmates were seen quickly and assessed by the
mental health staff. Specifically, eleven out of eleven charts reviewed demonstrated rapid and
appropriate referrals to mental health services. Further, the inmates interviewed in a pretrial unit
by the Monitoring Team denied having difficulty accessing mental health services. One of the
charts demonstrated that at least one new intake should have been referred to mental health upon
screening in July 2007.
In addition, the Monitoring Team found one case in which an older woman was
referred to mental health from intake, but refused further assessment. The Monitoring Team
believes that follow-up in that case could have been better. Despite noting that the woman was
“mildly MR,” and would not listen or understand, no follow-up was scheduled. Four days later,
nursing staff made another referral to mental health for the woman after she urinated on the
floor. The record does not reflect any follow-up from mental health until four days later. The
notes from that follow-up reflect that the inmate was cooperative, but no history was taken. The
Monitoring Team interacted with the woman and believed that further assessment should have
been done, and asked for such assessments to be done. The Monitoring Team believes that the
woman should have been placed on the mental health caseload and referred for psychiatric
97

evaluation. One isolated instance, such as is recounted here, is not sufficient to prevent the State
from earning the substantial compliance assessment noted below. See MOA ¶ 61.
2.

Assessment

The Monitoring Team found that Baylor is in substantial compliance with this
provision of the MOA.
C.

DCC
1.

Findings

The Monitoring Team found that the inmate self-referral program was
problematic. This was evidenced by a recent suspension of a mental health clinician assigned to
maximum security housing units who had not been responding to self-referrals from August
2007 to December 2007.
2.

Assessment

The Monitoring Team found that DCC is in partial compliance with this provision
of the MOA.
D.

HRYCI
1.

Findings

At the time of the Monitoring Team’s visit, the Monitoring Team found that sick
call slips for mental health care were being processed timely, reaching the appropriate mental
health staff, and triaged on a timely basis. In the past, this function had not been completed
reliably.
The process that was in place for responding in a timely fashion to mental health
referrals at the time of the Monitoring Team’s visit was that a clerk would print out the referrals
from DACS Monday through Friday, and there were individuals assigned to performing that task
on Saturdays and Sundays. Thus, referrals are being printed seven days a week.
The process that was in place for responding in a timely fashion to sick call slips
was that they were picked up every morning by nursing staff. This was an improvement from
prior visits by the Monitoring Team, which revealed that sick call slips were not picked up
reliably. The mental health sick call slips were separated and placed in a wall bin assigned for
mental health sick call slips. The next morning, mental health staff would pick up these sick call
slips. Thus, the timeliness of mental health sick call has improved.
Both the referrals and sick call slips are alphabetized, entered in the sick call and
referral log, assigned to the appropriate mental health clinician by housing area, and placed into
the mental health clinicians’ mailboxes, to be seen within 24 hours. On weekends, all sick calls

98

and referrals are assigned to the mental health staff providing coverage, regardless of housing
area.
The mental health staff is initialing and dating the entries in the sick call and
referral log when inmates have been seen. All mental health contacts, including psychiatry
visits, are entered into DACS by the mental health clerk.
2.

Assessment

The Monitoring Team found that HRYCI is in partial compliance with this
provision of the MOA.
E.

SCI
1.

Findings

The Monitoring Team found that mental health staff provides rapid evaluations on
cases referred to them once the referral is received. The Monitoring Team found that there was a
learning curve with the new DACS, in that SCI had some difficulty with accessing the
appropriate DACS-generated report in order to be aware of all of the referrals coming through
the system, but with education, it appears that this issue has been resolved.
2.

Assessment

The Monitoring Team found that SCI is in partial compliance with this provision
of the MOA.
F.

Recommendation

At DCC, the Monitoring Team recommends that the State: (i) implement a
procedure to ensure timely and appropriate responses to all referrals, including patient generated
referrals; and (ii) monitor this process with regard to timeliness and appropriateness of the
responses.
The Monitoring Team recommends that the State begin self-monitoring the
timeliness and appropriateness of Mental Health assessments and referrals at SCI.
35.

Mental Health Treatment Plans
A.

Relevant MOA Provision
Paragraph 35 of the MOA provides:
The State shall ensure that a qualified mental health professional prepares
in a timely manner and regularly updates an individual mental health
treatment plan for each inmate who requires mental health services. The

99

State shall also ensure that the plan is timely and consistently
implemented. Implementation of and any changes to the plan shall be
documented in the inmate’s medical/mental health record.
A mental health treatment plan should include, at a minimum, a description of: (i)
the frequency of follow-up for medical evaluation and adjustment of treatment modality; (ii) the
type and frequency of diagnostic testing and therapeutic regimens; and (iii) when appropriate,
instructions about diet, exercise, adaptation to the correctional environment, and medication. JG-01; P-G-01. Further, the plans should include ways to address the patients’ problems and
enhance their strengths, involve patients in their development, and include relapse prevention
risk management strategies, which should describe signs and symptoms associated with relapse
or recurring difficulties, how the patient thinks that a relapse can be averted, and how best to
help him or her manage crises that occur. Id.
B.

Baylor
1.

Findings

The Monitoring Team found that the treatment plans are completed, but they lack
specificity for individual inmates.
2.

Assessment

The Monitoring Team found that Baylor is in partial compliance with this
provision of the MOA.
C.

DCC
1.

Findings

The Monitoring Team found that treatment plans were completed in all charts
reviewed, but were not useful in that they lacked measurable goals and objectives. Most of the
plans reviewed by the Monitoring Team cluster all mental health problems together, and list the
outcomes as an increase in reports of mental health symptoms rather than how and to what extent
symptoms will be reduced. In addition, rather than a progress update being included every 90
days, the plan is completely rewritten every 90 days. An update rather than a re-write would be
more helpful in tracking the inmate’s progress. Finally, the treatment plans indicate that the
treatment the inmate receives is likely not individualized.
2.

Assessment

The Monitoring Team found that DCC is in partial compliance with this provision
of the MOA.
D.

HRYCI

100

1.

Findings

The Monitoring Team found that in some cases, treatment plans were not present
in inmates’ files. In addition, the treatment plans reviewed were particularly weak from the
perspective of planned interventions, and often lacked individualization. Inmate interviews
revealed that their meetings with the mental health clinicians were brief welfare checks in
contrast to counseling sessions.
2.

Assessment

The Monitoring Team found that HRYCI is in partial compliance with this
provision of the MOA.
E.

SCI
1.

Findings

The Monitoring Team found that, in the charts reviewed, treatment plans were
located which had a patient signature and 90-day updates. The Monitoring Team found that the
treatment plans focused on the medications that the inmate receives but do not address
psychosocial needs or include programming alternatives.
2.

Assessment

The Monitoring Team found that SCI is in partial compliance with this provision
of the MOA.
F.

Recommendation

At Baylor, the Monitoring Team recommends that the State implement training so
that treatment plans include more patient-specific components.
At DCC, the Monitoring Team recommends that the State create a redesigned
treatment plan program that addresses the issues raised in the findings section for that Facility.
At HRYCI, the Monitoring Team recommends that the State create a plan that
results in more individualized treatment plans, and enhanced quality of counseling sessions.
At SCI, the Monitoring Team recommends that the State implement training of
staff regarding a comprehensive approach to treatment plans.
36.

Crisis Services
A.

Relevant MOA Provision
Paragraph 36 of the MOA provides:

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The State shall ensure an adequate array of crisis services to appropriately
manage psychiatric emergencies. Crisis services shall not be limited to
administrative/disciplinary isolation or observation status. Inmates shall
have access to appropriate in-patient psychiatric care when clinically
appropriate.
An adequate array of crisis services should include not only observation
beds, but also some form of a crisis intervention specialist or team.
B.

Baylor
The Monitoring Team did not assess Baylor’s compliance with this provision of

the MOA.
C.

DCC
1.

Findings

The Monitoring Team found that the inadequate psychiatric staffing has resulted
in significant coverage and treatment issues within the infirmary. See discussion of provision 30
of the MOA. Those problems are exacerbated by a lack of adequate space in the infirmary.
2.

Assessment

The Monitoring Team found that DCC is in partial compliance with this provision
of the MOA.
D.

HRYCI
1.

Findings

The problems that the Monitoring Team found were that crisis care services in the
infirmary lack adequate office space for meeting with inmates in an office setting for adequate
sound privacy. Based on the Monitoring Team’s observations, initial crisis assessments are
taking place in an area that does not afford sufficient privacy.
2.

Assessment

The Monitoring Team found that HRYCI is in partial compliance with this
provision of the MOA.
E.

SCI
The Monitoring Team did not assess SCI’s compliance with this provision of the

MOA.

102

F.

Recommendation

At DCC, the Monitoring Team recommends that the State create a plan that
addresses the issues described in the above findings.
At HRYCI, the Monitoring Team recommends that the State create a plan that
ensures a professional appropriate environment for mental health assessments, including the
ability to discuss confidential information.
37.

Treatment for Seriously Mentally Ill Inmates
A.

Relevant MOA Provision
Paragraph 37 of the MOA provides:
The State shall ensure timely and appropriate therapy, counseling, and
other mental health programs for all inmates with serious mental illness.
This includes adequate space for treatment, adequate staff to provide
treatment, and an adequate array of therapeutic programming. The State
shall ensure that inmates who are being treated with psychotropic
medications are seen regularly by a physician to monitor responses and
potential reactions to those medications, in accordance with generally
accepted correctional mental health care standards.

This provision of the MOA will assist the State with providing continuity of
mental health care, and provides a complete general standard against which to assess the State’s
compliance with this provision of the MOA, or the standards are discussed with regard to other
provisions of the MOA (see, e.g., discussions of provisions 6, 18, 24, 25, 31 and 33 of the
MOA). To the extent that further clarification of appropriate standards is necessary, such
clarification will be stated in the findings.
B.

Baylor
1.

Findings

Seriously mentally ill inmates are being seen on a monthly basis by the mental
health staff, and have regularly scheduled psychiatric appointments. At the time of the
Monitoring Team’s visit, therapeutic group programming in the Harbor House unit was in
disarray for the seriously mentally ill inmates. The State has informed the Monitoring Team that
remedial actions with respect to Harbor House have been taken. Unfortunately, some psychiatric
visits have been taking place every 90 days, which is a frequency not responsive to the needs of
the patient. In addition, medication side effects, laboratory monitoring, and dosing regimens are
problematic as mentioned above. The most recent psychiatrist’s practices are an improvement
over previous providers and the Monitoring Team is optimistic positive changes will be
instituted by the time of the next audit.
2.

Assessment

103

The Monitoring Team found that Baylor is in partial compliance with this
provision of the MOA.
C.

DCC
1.

Findings

The Monitoring Team found that there is a problem with a lack of adequate
therapeutic group programming for the seriously mentally ill inmates.
Further, the
individualized treatment plans are not adequate in form or in function, and should be completed
with the inmate’s input, not presented as a completed document for signature.
The special needs units are comprised of two housing units, with a maximum
capacity of 49 inmates per unit. At the time of the Monitoring Team’s visit, both units were
under capacity.
The Monitoring Team interviewed inmates and two day-shift correctional officers
in one of the units. The inmates told the Monitoring Team that the correctional officers point
and laugh at them, which intensifies their sense of paranoia. Both of the officers interviewed had
not completed the four-hour mental health training, but, based on the inmate reports, the
correctional officers later received additional training.
2.

Assessment

The Monitoring Team found that DCC is in partial compliance with this provision
of the MOA.
D.

HRYCI
1.

Findings

The Monitoring Team refers to the findings discussed in reference to paragraph
29 of the MOA.
2.

Assessment

The Monitoring Team found that HRYCI is in partial compliance with this
provision of the MOA.
E.

SCI
1.

Findings

The Monitoring Team found that mental health staff sees inmates every 30 days
for well-being checks, and in response to sick call requests, but ongoing programming services

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are limited. The Monitoring Team further found that patients receiving medication are not being
monitored adequately for adverse reactions or negative side effects.
2.

Assessment

The Monitoring Team found that SCI is in partial compliance with this provision
of the MOA.
F.

Recommendation

At Baylor, the Monitoring Team recommends that the State create a plan to
address the issues raised in the findings.
At DCC, the Monitoring Team recommends that the State create a plan that
addresses the findings raised above in regard to individualized treatment plans, an elimination of
program lapses, standing hours of service, including the patient in treatment plan in design, and
stabilizing correctional officer staffing where seriously mentally ill patients are housed.
At HYRCI, the Monitoring Team recommends that the State create a plan to
address the issues addressed in the findings above, regarding housing and management of
patients in the programs for serious mental illness.
At SCI, the Monitoring Team recommends that the State (i) implement clinical
protocols consistent with community standards regarding monitoring of specific psychotropic
medications; (ii) implement self-monitoring of clinical monitoring.
38.

Review of Disciplinary Charges for Mental Illness Symptoms
A.

Relevant MOA Provision
Paragraph 38 of the MOA provides:
The State shall ensure that disciplinary charges against inmates with
serious mental illness who are placed in Isolation are reviewed by a
qualified mental health professional to determine the extent to which the
charge may have been related to serious mental illness, and to determine
whether an inmate’s serious mental illness should be considered by the
State as a mitigating factor when punishment is imposed on inmates with a
serious mental illness.

This provision of the MOA will assist the State with providing continuity of
mental health care, and provides a complete general standard against which to assess the State’s
compliance with this provision of the MOA. To the extent that further clarification of
appropriate standards is necessary, such clarification will be stated in the findings.
B.

Baylor

105

The Monitoring Team did not assess Baylor’s compliance with this provision of
the MOA.
C.

DCC
1.

Findings

The Monitoring Team found that mental health staff did not have any formal
input into the disciplinary process; the only input that occurs, happens when a correctional
officer comes to them to receive a verbal report. At the time of the Monitoring Team’s visit, the
State was in the process of developing a policy relevant to this requirement.
2.

Assessment

The Monitoring Team found that DCC is not in compliance with this provision of
the MOA.
D.

HRYCI
1.

Findings

The Monitoring Team found that hearing officers receive input verbally from the
mental health supervisor concerning mentally ill inmates in isolation. The mental health
clinician does not always see the incident report or interview the inmate. At the time of the
Monitoring Team’s visit, the State was in the process of developing a policy relevant to this
requirement.
2.

Assessment

The Monitoring Team found that HRYCI is in partial compliance with this
provision of the MOA.
E.

SCI
1.

Findings

The Monitoring Team found that medical and mental health staff could complete
an incident report at the time of an occurrence, but the Monitoring Team was unable to
determine if mental health staff’s input is solicited if they fail to submit a report on their own.
As discussed above, the Monitoring Team was informed of an inmate incident in
which mental health staff were not given the opportunity to provide adequate input to the
disciplinary process.
2.

Assessment

106

The Monitoring Team found that SCI is in partial compliance with this provision
of the MOA.
F.

Recommendation

At DCC, the Monitoring Team recommends that the State develop and implement
a policy and procedure that includes the following elements: (i) the criteria that triggers a mental
health assessment/input relevant to the disciplinary process; (ii) the question(s) to be addressed
by the mental health assessment; (iii) the nature of the assessment (e.g., interview, review of
incident reports, etc.); (iv) how the mental health input is to be utilized by the hearing officer,
and (v) how the mental health input process will be assessed relevant to its impact.
At HYRCI, the Monitoring Team recommends that the State develop and
implement a policy and procedure that includes the following elements: (i) the criteria that
triggers a mental health assessment/input relevant to the disciplinary process; (ii) the question(s)
to be addressed by the mental health assessment; (iii) the nature of the assessment (e.g.,
interview, review of incident reports, etc.); (iv) how the mental health input is to be utilized by
the hearing officer, and (v) how the mental health input process will be assessed relevant to its
impact.
At SCI, the Monitoring Team recommends that the State create a plan that
facilitates Mental Health input regarding disciplinary incidents for patients on the Mental Health
caseload.
39.

Procedures for Mentally Ill Inmates in Isolation or Observation Status
A.

Relevant MOA Provision
Paragraph 39 of the MOA provides:
The State shall implement policies, procedures, and practices consistent
with generally accepted professional standards to ensure that all mentally
ill inmates on the facility’s mental health caseload and who are housed in
Isolation receive timely and appropriate treatment, including completion
and documentation of regular rounds in the Isolation units at least once per
week by qualified mental health professionals in order to assess the
serious mental health needs of those inmates. Inmates with serious mental
illness who are placed in Isolation shall be evaluated by a qualified mental
health professional within twenty-four [sic] hours and regularly thereafter
to determine the inmate’s mental health status, which shall include an
assessment of the potential effect of the Isolation on the inmate’s mental
health. During these regular evaluations, the State shall evaluate whether
continued Isolation is appropriate for that inmate, considering the
assessment of the qualified mental health professional, or whether the
inmate would be appropriate for graduated alternatives. The State shall
adequately document all admissions to, and discharges from, Isolation,
including a review of treatment by a psychiatrist. The State shall provide

107

adequate facilities for observation, with no more than two inmates per
room.
This provision of the MOA makes clear that those inmates already on the mental
health caseload must receive appropriate and timely treatment, regardless of their status as being
in isolation. This means that these inmates must have adequate access to mental health care. See
J-E-07; P-E-07. According to this MOA language, this treatment includes, but is not limited to,
weekly rounds in the isolation units. See discussion of provision 20 above.
B.

Baylor
1.

Findings

At the time of the Monitoring Team’s visit, there were no inmates in isolation, but
the Monitoring Team was able to observe segregation rounds, which occur according to
appropriate standards.
2.

Assessment

The Monitoring Team found that Baylor is in substantial compliance with this
provision of the MOA.
C.

DCC
1.

Findings

The Monitoring Team found that, pursuant to the requirements contained in
paragraph 20 of the MOA, mental health rounds are taking place three days per week in the
segregation units (i.e., that houses administrative, disciplinary and protective custody inmates).
The Monitoring Team found that there is not a process in place to notify mental
health staff of newly admitted inmates to isolation within 24 hours of their admission.
Additionally, mental health staff do not evaluate such inmates within 24 hours to determine the
inmate’s mental health status, which should include an assessment of the potential effect of the
isolation on the inmate’s mental health.
Based on review of the isolation progress notes form present in segregated
inmates’ health records, as well as direct observation of rounds, the Monitoring Team found that
the initial evaluation (regardless of the time frame of such an evaluation) does not appear to be
any different than the welfare check performed during the mental health rounds process. It is the
Monitoring Team’s belief that the initial assessment should minimally include a brief suicide risk
assessment that should be performed out of cell in an office setting unless the inmate refuses to
participate in such a setting. Regarding the provision that the “State shall adequately document
all admissions to, and discharges from Isolation [our interpretation—the infirmary], including a
review of treatment by a psychiatrist. The State shall provide adequate facilities for observation,

108

with no more than two inmates per room,” there is partial compliance. Problems relevant to
physical plant issues and lack of daily presence of a psychiatrist onsite remain.
2.

Assessment

The Monitoring Team found that DCC is in partial compliance with this provision
of the MOA.
D.

HRYCI
1.

Findings

The Monitoring Team found that, pursuant to the requirements contained in
paragraph 20 of the MOA, mental health rounds are taking place three days per week in the
segregation units (i.e., that houses administrative, disciplinary and protective custody inmates).
The rounds assignments are rotated among all staff rather than assigning one or two clinicians to
this duty for three to six month rotations, which can affect the continuity of care provided to
these inmates. These rounds were reported to take one-half hour to an hour.
The Monitoring Team found that HRYCI did not have a process in place to ensure
that mental health staff is notified within 24 hours of their admission to isolation. Additionally,
mental health staff does not evaluate such inmates within 24 hours to determine the inmate’s
mental health status, which shall include an assessment of the potential effect of the isolation on
the inmate’s mental health.
The Monitoring Team found that, upon a review of progress notes in inmate’s
medical records and direct observation, the initial evaluation amounted to a welfare check that
was no different than that performed by mental health staff during regular rounds. The
evaluation should include, at a minimum, a brief suicide risk assessment performed out-of-cell in
an office setting, unless the inmate refuses to participate in such a setting.
The Monitoring Team found that HRYCI has problems relevant to physical plant
issues and the lack of the daily presence of a psychiatrist on-site.
2.

Assessment

The Monitoring Team found that HRYCI is in partial compliance with this
provision of the MOA.
E.

SCI
1.

Findings

The Monitoring Team found that segregation rounds are occurring three times per
week, but that the progress notes related to these rounds were identical regardless of the inmate
seen and what day of the week they were seen. These notes revealed an inadequacy in the

109

rounds. Also, the Monitoring Team reviewed one inmate who appeared to be mentally ill and
had been seen on three occasions by two different mental health counselors (once by one mental
health counselor and twice by another mental health counselor). The progress notes for this
inmate ranged from an assessment of a completely normal mental status exam to an assessment
that demonstrated significant psychopathology.
2.

Assessment

The Monitoring Team found that SCI is in partial compliance with this provision
of the MOA.
3.

Recommendation

At DCC, the Monitoring Team recommends that the State create a plan that
facilitates mental health input into the disciplinary process.
At HYRCI, the Monitoring Team recommends that the State and the DOJ clarify
the provision.
At SCI, the Monitoring Team recommends that the State begin monitoring its
compliance with the applicable policies and procedures.
40.

Mental Health Services Logs and Documentation
A.

Relevant MOA Provision
Paragraph 40 of the MOA provides:
The State shall ensure that the State maintains an updated log of inmates
receiving mental health services, which shall include both those inmates
who receive counseling and those who receive medication. The log shall
include each inmate’s name, diagnosis or complaint, and next scheduled
appointment. Each clinician shall have ready access to a current log listing
any prescribed medication(s) and dosages for inmates on psychotropic
medications. In addition, inmate’s files shall contain current and accurate
information regarding any medication changes ordered in at least the past
year.

This provision of the MOA will assist the State with providing continuity of
mental health care, and provides a complete general standard against which to assess the State’s
compliance with this provision of the MOA. To the extent that further clarification of
appropriate standards is necessary, such clarification will be stated in the findings.
B.

Baylor
1.

Findings

110

The Monitoring Team observed that Baylor maintains a computerized chronic
care list in compliance with this provision of the MOA.
2.

Assessment

The Monitoring Team found that Baylor is in substantial compliance with this
provision of the MOA.
C.

DCC
1.

Findings

The Monitoring Team found that all of the elements required by the MOA are
contained in a spreadsheet.
2.

Assessment

The Monitoring Team found that DCC is in substantial compliance with this
provision of the MOA.
D.

HRYCI
1.

Findings

The Monitoring Team found that the tracking spreadsheet at HRYCI generally
contains the dosages of medication prescribed. In addition, the State has implemented a new
DACS, which was expanded from the original version to include healthcare-related information.
The Monitoring Team found that the spreadsheet should be revised to include the date of the
inmate’s next scheduled appointment.
2.

Assessment

The Monitoring Team found that HRYCI is in partial compliance with this
provision of the MOA.
E.

SCI
1.

Findings

The Monitoring Team found that a current and comprehensive database is
maintained by the mental health staff at SCI, but based upon a chart review, in spite of that
database, some inmates were missed.
2.

Assessment

111

The Monitoring Team found that SCI is in partial compliance with this provision
of the MOA.
F.

Recommendation

At HRYCI, the Monitoring Team recommends that the spreadsheet used by the facility be
revised to include the inmate’s next scheduled appointment.
At SCI, the Monitoring Team recommends that the facility implement self-monitoring for
completeness of Mental Health Services tracking.

112

SUICIDE PREVENTION
41.

Suicide Prevention Policy
A.

Relevant MOA Provision
Paragraph 41 of the MOA provides:
The State shall review and, to the extent necessary, revise its suicide
prevention policy to ensure that it includes the following provisions: 1)
training; 2) intake screening/assessment; 3) communication; 4) housing; 5)
observation; 6) intervention; and 7) mortality and morbidity review.

The MOA provides the complete standard against which the State is to be
assessed for this provision of the MOA. The required substance of the required policy is, in
large part, set forth in the MOA provisions and standards applying to each of the categories
enumerated in this provision of the MOA.
The Monitoring Team found that the State is in substantial compliance with this
provision of the MOA, because it has an adequate suicide prevention policy in place. The
Monitoring Team notes that this provision of the MOA does not relate to the implementation of
the suicide prevention policy; this provision requires only that the State review and revise its
policy. Therefore, this rating of substantial compliance should not be construed as assessing the
State in substantial compliance with the implementation of its suicide prevention policy.
42.

Suicide Prevention Training Curriculum
A.

Relevant MOA Provision
Paragraph 42 of the MOA provides:
The State shall review and, to the extent necessary, revise its suicide
prevention training curriculum, which shall include the following topics:
1) the suicide prevention policy as revised consistent with this Agreement;
2) why facility environments may contribute to suicidal behavior; 3)
potential predisposing factors to suicide; 4) high risk suicide periods; 5)
warning signs and symptoms of suicidal behavior; 6) case studies of recent
suicides and serious suicide attempts; 7) mock demonstrations regarding
the proper response to a suicide attempt; and 8) the proper use of
emergency equipment.

The MOA provides the complete standard against which the State is to be
assessed for this provision of the MOA. The required substance of the training curriculum is, in
large part, set forth in the MOA provisions and standards applying to each of the categories
enumerated in this provision of the MOA.
The Monitoring Team found that the State is in substantial compliance with this
provision of the MOA, because it has an adequate suicide prevention training curriculum. The
113

Monitoring Team notes that this provision of the MOA requires the State to review and revise its
suicide prevention training curriculum, and does not relate to conducting the training. Thus, the
Monitoring Team’s assessment of substantial compliance is limited only to an assessment that
the State has reviewed and revised its suicide prevention training curriculum.
43.

Staff Training
A.

Relevant MOA Provision
Paragraph 43 of the MOA provides:
Within twelve months of the effective date of this Agreement, the State
shall ensure that all existing and newly hired correctional, medical, and
mental health staff receive an initial eight-hour training on suicide
prevention curriculum described above. Following completion of the
initial training, the State shall ensure that a minimum of two hours of
refresher training on the curriculum are completed by all correctional care,
medical, and mental health staff each year.

This provision of the MOA provides a complete general standard against which to
assess the State’s compliance with this provision of the MOA. To the extent that further
clarification of appropriate standards is necessary, such clarification will be stated in the
findings.
B.

Baylor

The Monitoring Team did not assess Baylor’s compliance with this provision of
the MOA. At the time of the Monitoring Team’s visit to Baylor to assess this provision of the
MOA, the policies were pending.
C.

DCC
1.

Findings

While the Monitoring Team found that all correctional and mental health staff had
received the initial training pursuant to the MOA, the Monitoring Team was unable to verify if
the medical staff had completed this training.
2.

Assessment

The Monitoring Team found that DCC is in partial compliance with this provision
of the MOA.
D.

HRYCI
1.

Findings

114

The Monitoring Team found that some of the medical staff had not yet received
the training required by this provision of the MOA. The Monitoring Team found that
correctional staff and mental health staff had been trained as required by the MOA.
2.

Assessment

The Monitoring Team found that HRYCI was in partial compliance with this
provision of the MOA.
E.

SCI
1.

Findings

The Monitoring Team found that more than half of the mental health staff had
completed the required training. Specifically, five of the seven mental health clinicians at SCI
have completed training and two new hires are waiting to be scheduled. The Monitoring Team
did not receive data on other medical staff.
2.

Assessment

The Monitoring Team found that SCI was in partial compliance with this
provision of the MOA.
44.

Intake Screening/Assessment
A.

Relevant MOA Provision
Paragraph 44 of the MOA provides:
The State shall develop and implement policies and procedures pertaining
to intake screening in order to identify newly arrived inmates who may be
at risk for suicide. The screening process shall include inquiry regarding:
1) past suicidal ideation and/or attempts; 2) current ideation, threat, plan;
3) prior mental health treatment/hospitalization; 4) recent significant loss
(job, relationship, death of family member/close friend, etc.); 5) history of
suicidal behavior by family member/close friend; 6) suicide risk during
prior confinement in a state facility; and 7) arresting/transporting officer(s)
belief that the inmate is currently at risk.

The requirement for intake screening and assessment to include these factors is
discussed above, with regard to provision 33 of the MOA.
B.

Baylor
1.

Findings

115

The Monitoring Team found that initial screens are completed in a timely fashion
and an internal audit from September 2007 indicates 100% compliance.
2.

Assessment

The Monitoring Team found that Baylor is in substantial compliance with this
provision of the MOA.
C.

DCC
1.

Findings

A review of records found that the intakes have been occurring pursuant to the
State’s policy.
2.

Assessment

The Monitoring Team found that DCC is in substantial compliance with this
provision of the MOA.
D.

HRYCI
1.

Findings

The Monitoring Team reviewed audits relevant to this provision of the MOA,
which were consistent with compliance although the size of the sampling was not adequate.
2.

Assessment

The Monitoring Team found that HRYCI is in substantial compliance with this
provision of the MOA.
E.

SCI
1.

Findings

The Monitoring Team found that all of the initial screens reviewed were complete
and included questions regarding suicide risk with elaboration when a positive response was
recorded, and those inmates were referred to mental health.
2.

Assessment

The Monitoring Team found that SCI is in substantial compliance with this
provision of the MOA.
45.

Mental Health Records

116

A.

Relevant MOA Provision
Paragraph 45 of the MOA provides:
Upon admission, the State shall immediately request all pertinent mental
health records regarding the inmate’s prior hospitalization, court-ordered
evaluations, medication, and other treatment. DOJ acknowledges that the
State's ability to obtain such records depends on the inmate's consent to
the release of such records.

This provision of the MOA provides a complete general standard against which to
assess the State’s compliance with this provision of the MOA. To the extent that further
clarification of appropriate standards is necessary, such clarification will be stated in the
findings.
B.

Baylor
1.

Findings

Upon review of health records, the Monitoring Team did not find any community
mental health records. It is not known whether the lack of community health records is due to
lack of requests or lack of responses to requests.
2.

Assessment

The Monitoring Team found that Baylor is not in compliance with this provision
of the MOA.
C.

DCC
1.

Findings

The Monitoring Team found that DCC requests that inmates complete the release
of information form during the intake process that takes place upon their arrival at a Facility, and
then the request form is sent. The clerk that is assigned to mental health functions will attempt to
send the release three times by facsimile to any outpatient provider identified by the inmate. The
response rate to the requests for information has been poor, but the reason for this poor response
rate has not been analyzed to determine if the form of request is inhibiting a response to the
request.
2.

Assessment

The Monitoring Team found that DCC is in partial compliance with this provision
of the MOA.
D.

HRYCI
117

1.

Findings

The Monitoring Team found that HRYCI follows the same process as DCC with
the same results.
2.

Assessment

The Monitoring Team found that HRYCI is in partial compliance with this
provision of the MOA.
E.

SCI
1.

Findings

Upon a review of health records, the Monitoring Team could find only one
instance in which there was documentation of a request for prior records.
2.

Assessment

The Monitoring Team found that SCI is not in compliance with this provision of
the MOA.
F.

Recommendation

At Baylor, the Monitoring Team recommends that the State implement
procedures to ensure timely request and tracking of community records.
At SCI, the Monitoring Team recommends that the State: (i) implement a
procedure to ensure prior mental health records are requested upon admission to the Department
of Correction; and (ii) implement self-monitoring of this procedure. The Monitoring Team
recommends that the State create a plan that addresses the more timely receipt of information
from outside providers.
46.

Identification of Inmates at Risk of Suicide
A.

Relevant MOA Provision
Paragraph 46 of the MOA provides:
Inmates at risk for suicide shall be placed on suicide precautions until they
can be assessed by qualified mental health personnel. Inmates at risk of
suicide include those who are actively suicidal, either threatening or
engaging in self-injurious behavior; inmates who are not actively suicidal,
but express suicidal ideation (e.g., expressing a wish to die without a
specific threat or plan) and/or have a recent prior history of selfdestructive behavior; and inmates who deny suicidal ideation or do not

118

threaten suicide, but demonstrate other concerning behavior (through
actions, current circumstances, or recent history) indicating the potential
for self-injury.
The MOA requires that the State place any inmate at risk for suicide68 on suicide
precautions until they can be assessed by qualified mental health personnel. Suicide precautions
refer to the housing and observation requirements set forth in paragraphs 49 through 51 below.
The State has developed a policy that suicide precautions will consist of placing the inmate under
constant observation by correctional staff in a safe cell while an order for placement on
psychiatric observation is obtained from the appropriate medical or mental health personnel. G05. The Monitoring Team finds that this policy conforms to generally accepted professional
standards. See J-G-05; P-G-05. As set forth in paragraph 47 below, the assessment by qualified
mental health personnel should be performed within 24 hours of the initiation of suicide
precautions.
B.

Baylor
1.

Findings

The Monitoring Team found that inmates are readily placed on watch if staff
determines that they are at risk of self-injury.
2.

Assessment

The Monitoring Team found that Baylor is in substantial compliance with this
provision of the MOA.
C.

DCC
1.

Findings

Specifically, the Monitoring Team found that, during its visit in September 2007,
DCC had problems implementing the daily monitoring by a mental health professional and the
one-day follow-up after discharge. The Monitoring Team noted significant improvement with
these problems during the December 2007 visit.
2.

Assessment

68

The MOA defines an “inmate at risk for suicide” as one who is (i) actively suicidal by
threatening or engaging in self-injurious behavior; (ii) not actively suicidal, but expresses
suicidal ideation; and/or has a recent prior history of self-destructive behavior; and (iii) who
denies suicidal ideation or does not threaten suicide, but demonstrates other concerning behavior
indicating the potential for self-injury.

119

The Monitoring Team found that DCC is in partial compliance with this provision
of the MOA.
D.

HRYCI
1.

Findings

The Monitoring Team found that the records of patients who had been placed on
suicide watch demonstrated that the State complied with the requirements above.
2.

Assessment

The Monitoring Team found that HRYCI is in substantial compliance with this
provision of the MOA.
E.

SCI
1.

Findings

Inmates at risk of suicide are rapidly assessed and moved to psychiatric
observation, and SCI follows the State’s policies.
2.

Assessment

The Monitoring Team found that SCI is in substantial compliance with this
provision of the MOA.
F.

Recommendation

At DCC, the Monitoring Team recommends that the State closely monitor this
area via the QI process.
47.

Suicide Risk Assessment
A.

Relevant MOA Provision
Paragraph 47 of the MOA provides:
The State shall ensure that a formalized suicide risk assessment by a
qualified mental health professional is performed within an appropriate
time not to exceed 24 hours of the initiation of suicide precautions. The
assessment of suicide risk by qualified mental health professionals shall
include, but not be limited to, the following: description of the antecedent
events and precipitating factors; suicidal indicators; mental status
examination; previous psychiatric and suicide risk history, level of
lethality; current medication and diagnosis; and recommendations/

120

treatment plan. Findings from the assessment shall be documented on both
the assessment form and health care record.
This provision of the MOA requires a formalized suicide risk assessment to be
performed by a qualified mental health professional69 within an appropriate period of time,
which, in any event, is not to exceed 24 hours of the initiation of suicide precautions as described
above in relation to paragraph 46 of the MOA. The formalized suicide risk assessment should
designate the individual’s level of suicide risk, level of supervision needed, and the need for
transfer to an inpatient mental health facility or program. J-G-05; P-G-05. In addition, the MOA
provides that the assessment of the individual’s level of suicide risk should include at least: (i) a
description of the antecedent events and precipitating factors; (ii) suicidal indicators; (iii) mental
status examination; (iv) previous psychiatric and suicide risk history, (v) level of lethality; (vi)
current medication and diagnosis; and (vii) recommendations/treatment plan.
B.

Baylor

The Monitoring Team deferred assessing Baylor’s compliance with this provision
of the MOA because they were not able to find any relevant cases.
C.

DCC

The Monitoring Team deferred assessing DCC’s compliance with this provision
of the MOA due to a lack of time. The Monitoring Team did observe, however, that the initial
evaluation form being used by the State for the purposes of the suicide risk assessment should be
modified to include current medication and diagnosis, so that the form will require that all
information required by the MOA to be recorded will be recorded.
D.

HRYCI
The Monitoring Team has the same comments regarding HRYCI as with DCC.

E.

SCI
1.

Findings

The Monitoring Team found that assessments are reliably and informatively
completed on all inmates placed on psychiatric observation and meet the time frames established
by the MOA.
2.

Assessment

69

The State has developed a policy that a mental health staff (i.e., an employee with a masters
degree or greater level of certification) is qualified for the purposes of initiating an order for
psychiatric observation, but that only a psychologist with a Ph.D., or a psychiatrist may
discharge or downgrade an inmate’s level of risk while on psychiatric observation. See State
Policy G-05. The Monitoring Team found that policy to be adequate.
121

The Monitoring Team found that SCI is in substantial compliance with this
provision of the MOA.
F.

Recommendation

At HRYCI, the Monitoring Team recommends that the State create a plan that
addresses the privacy issues and improvement in the psychiatric observation, initial evaluation
forms as described in the findings.
48.

Communication
A.

Relevant MOA Provision
Paragraph 48 of the MOA provides:
The State shall ensure that any staff member who places an inmate on
suicide precautions shall document the initiation of the precautions, level
of observation, housing location, and conditions of the precautions. The
State shall develop and implement policies and procedures to ensure that
the documentation described above is provided to mental health staff and
that in-person contact is made with mental health staff to alert them of the
placement of an inmate on suicide precautions. The State shall ensure that
mental health staff thoroughly review an inmate’s health care record for
documentation of any prior suicidal behavior. The State shall promulgate a
policy requiring mental health to utilize progress notes to document each
interaction and/or assessment of a suicidal inmate. The decision to
upgrade, downgrade, discharge, or maintain an inmate on suicide
precautions shall be fully justified in each progress note. An inmate shall
not be downgraded or discharged from suicide precautions until the
responsible mental health staff has thoroughly reviewed the inmate’s
health care record, as well as conferred with correctional personnel
regarding the inmate’s stability. Multidisciplinary case management team
meetings (to include facility officials and available medical and mental
health personnel) shall occur on a weekly basis to discuss the status of
inmates on suicide precautions.

This provision of the MOA provides a complete general standard against which to
assess the State’s compliance with this provision of the MOA. To the extent that further
clarification of appropriate standards is necessary, such clarification will be stated in the
findings.
B.

Baylor

The Monitoring Team deferred assessing Baylor’s compliance with this provision
of the MOA because no relevant cases were found.

122

C.

DCC
1.

Findings

The Monitoring Team found that the multidisciplinary team meetings are taking
place on a weekly basis, and at the meeting observed by the Monitoring Team, there was very
good multidisciplinary discussion generated that centered essentially on current status and
management plans for many difficult mental caseload inmates. The psychiatrist was not present
at that meeting, which means that vital input might be missed.
2.

Assessment

The Monitoring Team found that DCC is in substantial compliance with this
provision of the MOA.
D.

HRYCI
1.

Findings

The Monitoring Team found that the multidisciplinary team meetings have not
been occurring regularly on a formal basis. The Monitoring Team did note, however, that
regular discussions regarding inmates on suicide precautions take place via security briefings that
have included both security personnel and mental health staff. The psychiatrist does not attend
the meetings, which means that vital input might be missed.
2.

Assessment

The Monitoring Team found that HRYCI is in partial compliance with this
provision of the MOA.
E.

SCI
1.

Findings

The Monitoring Team observed that all inmates on suicide precautions have
individualized forms posted on their observation cell door specifying the level of watch and to
what property they have access.
2.

Assessment

The Monitoring Team found that SCI is in substantial compliance with this
provision of the MOA.
F.

Recommendation

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At HRYCI, the Monitoring Team recommends that the State implement a
multidisciplinary case management team consistent with the requirements of this paragraph.
49.

Housing
A.

Relevant MOA Provision
Paragraph 49 of the MOA provides:
The State shall ensure that all inmates placed on suicide precautions are
housed in suicide-resistant cells (i.e., cells without protrusions that would
enable inmates to hang themselves). The location of the cells shall
provide full visibility to staff. At the time of placement on suicide
precautions, medical or mental health staff shall write orders setting forth
the conditions of the observation, including but not limited to allowable
clothing, property, and utensils, and orders addressing continuation of
privileges, such as showers, telephone, visiting, recreation, etc.,
commensurate with the inmate's security level. Removal of an inmate’s
prison jumpsuit (excluding belts and shoelaces) and the use of any
restraints shall be avoided whenever possible, and used only as a last
resort when the inmate is engaging in self-destructive behavior. The
Parties recognize that security and mental health staff are working towards
the common goal of protecting inmates from self-injury and from harm
inflicted by other inmates. Such orders must therefore take into account all
relevant security concerns, which can include issues relating to the
commingling of certain prison populations and the smuggling of
contraband. Mental health staff shall give due consideration to such
factors when setting forth the conditions of the observation, and any
disputes over the privileges that are appropriate shall be resolved by the
Warden or his or her designee. Scheduled court hearings shall not be
cancelled because an inmate is on suicide precautions.

This provision of the MOA provides a complete general standard against which to
assess the State’s compliance with this provision of the MOA. To the extent that further
clarification of appropriate standards is necessary, such clarification will be stated in the
findings. The State has developed a policy that addresses these issues with more specificity. See
State Policy G-05. The State’s policy classifies differing levels of suicide risk as Levels I
through III.
B.

Baylor
1.

Findings

The Monitoring Team found that the infirmary at Baylor has enough space to
accommodate three inmates on suicide precautions. If there is a need for more space, the
inmates are housed in a clean cell on the isolation wing with one-to-one observation.

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The Monitoring Team found that inmates’ housing while on suicide precaution is
not specifically tailored to a given inmate’s suicide precaution level. The Monitoring Team
found that all inmates are allowed access to the same items, regardless of their suicide precaution
level. Each inmate receives a Ferguson blanket, gown, and finger foods. None of the inmates on
suicide precautions receive a mattress unless medically indicated.
2.

Assessment

The Monitoring Team found that Baylor is in partial compliance with this
provision of the MOA.
C.

DCC
1.

Findings

One problem that the Monitoring Team observed is that there are 10 suicideresistant cells, but one of these cells has a “toilet,” which essentially is a hole in the ground.
Such a toilet is not clinically appropriate and is dehumanizing. The Monitoring Team observed
that DCC is providing shred-resistant mattresses, which allows inmates on suicide precautions to
have a mattress, without presenting an unreasonable risk of allowing that inmate to injure
himself.
2.

Assessment

The Monitoring Team found that DCC is in partial compliance with this provision
of the MOA.
D.

HRYCI
1.

Findings

The Monitoring Team found the State provides shred resistant mattresses, suicideresistant blankets, and Ferguson gowns. The Monitoring Team found that two of the cells used
for suicide precautions had the same type of toilet as described above with regard to DCC.
Inmates are allowed to attend court hearings.
2.

Assessment

The Monitoring Team found that HRYCI is in partial compliance with this
provision of the MOA.
E.

SCI
1.

Findings

125

The Monitoring Team found that all inmates on observation levels I and II (as
defined by State policy) are housed in the infirmary in clean cells, and inmates on observation
level III are housed either in the infirmary if space is available, or in another area. The property
that each inmates is allowed is listed on the forms specifying the inmate’s watch level. Inmates
are consistently given safety gowns and blankets, and maintained on a 15-minute watch. The
Monitoring Team found that the watch logs are completed and filed in the inmate’s health
records. The Monitoring Team did not find any omissions. Therefore, the Monitoring Team
found that the appropriate housing conditions for an inmate on suicide precaution are
documented and carried out appropriately.
2.

Assessment

The Monitoring Team found that SCI is in substantial compliance with this
provision of the MOA.
F.

Recommendation

At DCC and HRYCI, the Monitoring Team recommends that the State develop a
plan to replace the toilets with more appropriate facilities.
50.

Observation
A.

Relevant MOA Provision
Paragraph 50 of the MOA provides:
The State shall develop and implement policies and procedures pertaining
to observation of suicidal inmates, whereby an inmate who is not actively
suicidal, but expresses suicidal ideation (e.g., expressing a wish to die
without a specific threat or plan) and/or has a recent prior history of selfdestructive behavior, or an inmate who denies suicidal ideation or does not
threaten suicide, but demonstrates other concerning behavior (through
actions, current circumstances, or recent history) indicating the potential
for self-injury, shall be placed under close observation status and observed
by staff at staggered intervals not to exceed every 15 minutes (e.g., 5, 10,
7 minutes). An inmate who is actively suicidal, either threatening or
engaging in self-injurious behavior, shall be placed on constant
observation status and observed by staff on a continuous, uninterrupted
basis. Mental health staff shall assess and interact with (not just observe)
inmates on suicide precautions on a daily basis.

This provision of the MOA provides a complete general standard against which to
assess the State’s compliance with this provision of the MOA. To the extent that further
clarification of appropriate standards is necessary, such clarification will be stated in the
findings.
B.

Baylor

126

The Monitoring Team deferred assessing Baylor’s compliance with this provision
of the MOA because there were no relevant cases.
C.

DCC
1.

Findings

The Monitoring Team found that there were some issues with the daily mental
health assessments which were occurring on a daily basis that appear to have been remedied, but
those assessments were significantly hampered by the lack of adequate sound privacy from either
correctional officers or other inmates.
2.

Assessment

The Monitoring Team found that DCC is in partial compliance with this provision
of the MOA.
D.

HRYCI
1.

Findings

The Monitoring Team found that while the daily mental health assessments were
occurring, those assessments were significantly hampered by the lack of adequate sound privacy
from either correctional officers or other inmates.
2.

Assessment

The Monitoring Team found that HRYCI is in partial compliance with this
provision of the MOA.
E.

SCI

The Monitoring Team deferred assessing SCI’s compliance with this provision of
the MOA because the policy was not final at the time the Monitoring Team visited the Facility to
monitor this provision.
F.

Recommendation

The Monitoring Team recommends that the State create a plan for DCC and
HRYCI to provide professionally appropriate space for mental health assessments.
51.

“Step-Down Observation”
A.

Relevant MOA Provision

127

Paragraph 51 of the MOA provides:
The State shall develop and implement a “step-down” level of observation
whereby inmates on suicide precaution are released gradually from more
restrictive levels of supervision to less restrictive levels for an appropriate
period of time prior to their discharge from suicide precautions. The State
shall ensure that all inmates discharged from suicide precautions continue
to receive follow-up assessment in accordance with a treatment plan
developed by a qualified mental health professional.
This provision of the MOA provides a complete general standard against which to
assess the State’s compliance with this provision of the MOA. To the extent that further
clarification of appropriate standards is necessary, such clarification will be stated in the
findings.
B.

Baylor

The Monitoring Team deferred assessing Baylor’s compliance with this provision
of the MOA because there were no relevant cases to review.
C.

DCC
1.

Findings

The State has developed a policy, and appears to have implemented it
appropriately. Although the Monitoring Team found that there had been issues with follow-up
that is required to occur with respect to inmates who have been stepped down, those issues
appear to have been corrected.
2.

Assessment

The Monitoring Team found that DCC is in partial compliance with this provision
of the MOA.
D.

HRYCI
1.

Findings

Audits have demonstrated relatively good compliance with the follow-up that is
required to occur within 24 hours, there are some problems with the required follow-up within
five to seven days, and compliance with the follow-up within 21 to 30 days.
2.

Assessment

The Monitoring Team found that HRYCI is in partial compliance with this
provision of the MOA.
128

E.

SCI
1.

Findings

The Monitoring Team found that all inmates are stepped down by a psychiatrist
order.
2.

Assessment

The Monitoring Team found that SCI is in substantial compliance with this
provision of the MOA.
F.

Recommendation

The Monitoring Team recommends that, at DCC and HRYCI, the State begin
and/or continue to monitor the performance of this provision of the MOA on a regular basis. The
Monitoring Team recommends that, at SCI, the State ensure that there is sufficient psychiatrist
time to avoid inmate’s having to staff on observation status for longer than necessary for the
simple reason that no psychiatrist is available to make the order.
52.

Intervention
A.

Relevant MOA Provision
Paragraph 52 of the MOA provides:
The State shall develop and implement an intervention policy to ensure
that all staff who come into contact with inmates are trained in standard
first aid and cardiopulmonary resuscitation; all staff who come into
contact with inmates participate in annual “mock drill” training to ensure a
prompt emergency response to all suicide attempts; and shall ensure that
an emergency response bag that includes appropriate equipment, including
a first aid kit and emergency rescue tool, shall be in close proximity to all
housing units. All staff who come into regular contact with inmates shall
know the location of this emergency response bag and be trained in its use.

As provided by the MOA, all staff coming into contact with the inmate should be
trained in standard first aid procedures and CPR. Further, the “mock drill” training should
include training for staff coming into contact with inmates regarding what to do when coming
into contact with an inmate engaging in self-harm, or who has engaged in self-harm. Hayes,
Lindsay M. Hayes, Guide to Developing and Revising Suicide Prevention Protocols, included as
Appendix C to the NCCHC Standards cited above. The staff member coming upon an inmate
engaging in self-harm should immediately survey the scene to assess the severity of the
emergency, alert other staff to call for medical personnel if necessary, and to start first aid and/or
CPR as necessary, even if the inmate appears to have died until relieved by arriving medical
personnel. Id. The emergency response equipment available to staff should be checked on a
129

daily basis to determine that it is in working order. Finally, all suicide attempts, regardless of
their severity should result in an immediate intervention and assessment by mental health staff.
Id.
B.

Baylor
The Monitoring Team did not assess Baylor’s compliance with this provision of

the MOA.
C.

DCC
The Monitoring Team did not assess DCC’s compliance with this provision of the

MOA.
D.

HRYCI
1.

Findings

The Health Service Administrator maintains records of mock drill training.
Additionally, all relevant staff are CPR trained.
2.

Assessment

The Monitoring Team found that HRYCI is in substantial compliance with this
provision of the MOA.
E.

SCI
The Monitoring Team did not assess SCI’s compliance with this provision of the

MOA.
53.

Mortality and Morbidity Review
A.

Relevant MOA Provision
Paragraph 53 of the MOA provides:
The State shall develop and implement policies, procedures, and practices
to ensure that a multidisciplinary review is established to review all
suicides and serious suicide attempts (e.g., those incidents requiring
hospitalization for medical treatment). At a minimum, the review shall
comprise an inquiry of: a) circumstances surrounding the incident; b)
facility procedures relevant to the incident; c) all relevant training received
by involved staff; d) pertinent medical and mental health services/reports
involving the victim; e) possible precipitating factors leading to the
suicide; and, f) recommendations, if any, for changes in policy, training,

130

physical plant, medical or mental health services, and operational
procedures. When appropriate, the review team shall develop a written
plan (and timetable) to address areas that require corrective action.
An appropriate procedure in the event of an inmate death from suicide or a serious
suicide attempt is one in which the State determines the appropriateness of clinical care that was
provided to the inmate, ascertains whether corrective action in the State’s policies, procedures, or
practices is warranted; and identifies trends that require further study. J-A-10; P-A-10. If the
inmate has committed suicide, the State should immediately notify the State of Delaware medical
examiner, and, within 30 days of the suicide, conduct a clinical mortality review70 and a
psychological autopsy71 in a manner consistent with this MOA provision, which provides the
minimum inquiries necessary for these studies. J-A-10; P-A-10.
B.

Baylor

The Monitoring Team deferred assessing Baylor’s compliance with this provision
of the MOA due to the pending finalization of new mortality and morbidity policies and
procedures.
C.

DCC

The Monitoring Team deferred assessing Baylor’s compliance with this provision
of the MOA due to the pending finalization of new mortality and morbidity policies and
procedures.
D.

HRYCI

The Monitoring Team deferred assessing DCC’s compliance with this provision
of the MOA due to the pending finalization of new mortality and morbidity policies and
procedures.
E.

SCI

The Monitoring Team deferred assessing Baylor’s compliance with this provision
of the MOA due to the pending finalization of new mortality and morbidity policies and
procedures.

70

A “clinical mortality review” is “an assessment of the clinical care provided and the
circumstances leading up to the death” in order to “identify any areas of patient care or the
system’s policies and procedures that can be improved.” J-A-10; P-A-10.
71

A “psychological autopsy” is “usually conducted by a psychologist or other qualified mental
health professional” and consists of “a written reconstruction of an individual’s life with an
emphasis on factors that may have contributed to the individual’s death.” J-A-10; P-A-10.
131

QUALITY ASSURANCE
54.

Policies and Procedures
A.

Relevant MOA Provision
Paragraph 54 of the MOA provides:
The State shall develop and implement written quality assurance policies
and procedures to regularly assess and ensure compliance with the terms
of this Agreement. These policies and procedures should include, at a
minimum: provisions requiring an annual quality management plan and
annual evaluation; quantitative performance measurement with tools to be
approved in advance by DOJ; tracking and trending of data; creation of a
multidisciplinary team; morbidity and mortality reviews with self-critical
analysis, and periodic review of emergency room visits and
hospitalizations for ambulatory-sensitive conditions.

The Facilities should create a comprehensive CQI program72 that performs the
following functions in a fashion that complements the requirements contained in this provision
of the MOA:
•

establishes a multidisciplinary quality improvement committee73 that
meets at least quarterly and designs quality improvement monitoring
activities, discusses the results, and implements corrective action;

•

reviews, at least annually, access to care, receiving screening, health
assessment, continuity of care (sick call, chronic disease management,
discharge planning), infirmary care, nursing care, pharmacy services,
diagnostic services, mental health care, dental care, emergency care, and
hospitalizations, adverse patient occurrences including all deaths, critiques
of disaster drills, environmental inspection reports, inmate grievances, and
infection control;

•

completes an annual review of the effectiveness of the CQI program by
reviewing minutes of its committee meetings;

72

A “comprehensive CQI program” is defined as including, “a multidisciplinary quality
improvement committee, monitoring of the areas specified in the compliance indicators, and an
annual review of the effectiveness of the CQI program itself.” J-A-06; P-A-06. “CQI” means
“Continuous Quality Improvement.”
73

A “multidisciplinary quality improvement committee” is defined as “a group of health staff
from various disciplines that designs quality improvement monitoring activities, discusses the
results, and implements corrective action. J-A-06; P-A-06.

132

•

performs at least one process quality improvement study74 a year; and

•

performs at least one outcome quality improvement study75 a year.

J-A-06; P-A-06.
B.

Baylor

The Monitoring Team deferred assessing Baylor’s compliance with this provision
of the MOA pending the adoption of final policies.
C.

DCC

The Monitoring Team did not assess DCC’s compliance with this provision of the
MOA pending the adoption of final policies.
D.

HRYCI
1.

Findings

The Monitoring Team found that one committee meeting had taken place. The
Monitoring Team found that there was not a disciplined approach to performing the functions
that such a committee is to perform.
With respect to mental health services, the Monitoring Team found HRYCI in
non-compliance. The QI process is very rudimentary with significant methodological problems
with the sample size and selection of the samples.
2.

Assessment

The Monitoring Team did not assess HRYCI’s compliance with this provision of
the MOA, but with respect to mental health services, the Monitoring Team found HRYCI not in
compliance with this provision of the MOA.
E.

SCI
The Monitoring Team did not assess SCI’s compliance with this provision of the

MOA.
55.

Corrective Action Plans

74

“Process quality improvement studies” are studies that “examine the effectiveness of the
health care delivery process.” J-A-06; P-A-06.
75

“Outcome quality improvement studies” are studies that “examine whether expected outcomes
of patient care were achieved.” J-A-06; P-A-06.
133

A.

Relevant MOA Provision
Paragraph 55 of the MOA provides:
The State shall develop and implement policies and procedures to address
problems that are uncovered during the course of quality assurance
activities. The State shall develop and implement corrective action plans
to address these problems in such a manner as to prevent them from
occurring again in the future.

This provision of the MOA requires that the State develop and implement policies
and procedures in response to the uncovering of problems during the quality assurance activities
that are discussed in paragraph 54 of the MOA. In addition, the State is required to develop and
implement corrective action plans to address these problems in such a manner as to prevent them
from occurring again in the future. The Monitoring Team suggests that an adequate corrective
action plan will include a description of the problem that has, the specific steps that the State
plans to take to remedy the problem, and a deadline for correction of the problem. Finally, the
State should make provisions for a responsible party to follow-up after the deadline to ensure
that the corrective action plan was followed appropriately.
B.

Baylor

The Monitoring Team did not assess Baylor’s compliance with this provision of
the MOA because final policy and procedure has not been completed.
C.

DCC

The Monitoring Team did not assess DCC’s compliance with this provision of the
MOA pending the completion of policies and procedures.
D.

HRYCI
The Monitoring Team did not assess HRYCI’s compliance with this provision of

the MOA.

E.

SCI
The Monitoring Team did not assess SCI’s compliance with this provision of the

MOA.

134

CONCLUSION
The State has been making progress towards the goal of becoming substantially
compliant with all of the MOA Provisions. However, the State has much work to do before this
goal can ultimately be obtained. While it is a positive sign to see the State is in non-compliance
with very few of the provisions (17 of 217 total provisions), the fact that the State is only in
substantial compliance with a small number of provisions (31 of 217 total provisions) shows the
amount of work the State still has to do. The assessment of partial compliance that the
Monitoring Team has used is a very broad designation and in some instances reflects minimal
progress that the State has made in eliminating the constitutional deficiencies that motivated the
parties to enter into the MOA. The Department of Correction and particularly the Office of
Health Services have been very cooperative in providing information and access to the
Monitoring Team as we have assessed the four facilities. We have every reason to believe that
this will continue.
The Third Report of the Monitoring Team will be issued in June 2008. During the
monitoring which will provide support for that report, the Monitoring Team looks forward to
seeing the impact of some of the remedial efforts taken by State that have not yet been monitored
or took place after the experts’ visits to facilities. Similarly, the Monitoring Team looks forward
to seeing the State’s implementation of some of the recommendations found in this Report,
which will hopefully aide the State in acquiring substantial compliance ratings for some of the
MOA Provisions. The Monitoring Team plans to continue to provide technical assistance to the
State through recommendations and advice which will improve medical and mental health care
in the facilities.
In the next report, all MOA provisions should have a rating. As a result, a baseline
assessment will be complete which will allow the Monitoring Team, and interested parties to see
the progress the State is making during future reports. For provisions that have been rated in this
second report, the Monitoring Team will be able to offer a comprehensive analysis in the Third
Report and will be able to provide a comparison with findings and assessments contained in this
report.
The Third Report might have a different format, and a different mode of assessment for
some provisions based on the substantial compliance metrics that should be finalized in the near
future by the parties. Finally, the next report will most likely reflect the addition of at least one
new member to the medical and mental health experts on the Monitoring Team.

135